TOBACCO WHO DOCUMENTS
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103rd Session
EB103.R11
Agenda item 3
29 January 1999
Towards a WHO framework convention on
tobacco control
The Executive Board,
Recognizing the leadership of WHO in the field of tobacco control, and having considered the report
of the Director-General on the Tobacco Free Initiative1 and the outline of expected activities,2
RECOMMENDS to the Fifty-second World Health Assembly, the adoption of the following
resolution:
The Fifty-second World Health Assembly,
Being deeply concerned by the escalation of smoking and other forms of tobacco use
worldwide, which resulted in the loss of at least 3.5 million human lives in 1998 and is expected to
cause at least 10 million deaths a year by 2030, with 70% of these deaths occurring in developing
countries if the pandemic is not controlled;
Having considered the report of the Director-General on the Tobacco Free Initiative and the
outline of expected activities (annexed);2
Recognizing the leadership of the Director-General and WHO in the field of tobacco control;
Recalling and reaffirming resolution WHA49.17 requesting the Director-General to initiate
development of a WHO framework convention on tobacco control in accordance with Article 19 of
the WHO Constitution;
Recognizing the need for multisectoral strategies, including the involvement of other
multilateral organizations and nongovernmental organizations, to foster international consensus and
action on development of the WHO framework convention on tobacco control and possible related
protocols;
Being mindful of the many constraints, including resource constraints, faced by a number of
countries in the development and implementation of the WHO framework convention on tobacco
control and possible related protocols;
1 Document EB103/5.
2 Annex.
EB103.R11
Being mindful of the fact that tobacco production is a significant source of earnings in many
developing countries;
Being aware of the urgent need to speed up work on the proposed WHO framework
convention on tobacco control and possible related protocols so that they may serve as a basis for
multilateral cooperation and collective action on tobacco control;
Desiring to complete preparation of the draft text of the framework convention for
consideration by the Fifty-sixth World Health Assembly;
1.
DECIDES:
(1)
in accordance with Rule 42 of its Rules of Procedure, to establish an intergovernmental
negotiating body open to all Member States to draft and negotiate the proposed WHO
framework convention on tobacco control and possible related protocols;
(2) to establish a working group on the WHO framework convention on tobacco control
open to all Member States in order to prepare the work of the body referred to above. This
group will prepare proposed draft elements of the WHO framework convention on tobacco
control. The working group will report on progress to the Executive Board at its 105th
session. It will complete its work and submit a report to the Fifty-third World Health
Assembly.
2.
URGES Member States:
(1) to give high priority to accelerating work on development of the WHO framework
convention on tobacco control and possible related protocols;
(2)
to provide resources and cooperation necessary to accelerate the work;
(3) to promote intergovernmental consultations to address specific issues, for example,
public health matters and other technical matters relating to negotiation of the proposed WHO
framework convention on tobacco control and possible related protocols;
(4) to establish national commissions for the WHO framework convention on tobacco
control where appropriate;
(5) to facilitate and support the participation of nongovernmental organizations,
recognizing the need for multisectoral representation;
(6) to consider further development and strengthening of national and regional tobacco
policies, including the appropriate use of regulatory programmes to reduce tobacco use, as
contributions to development of the framework convention and possible related protocols;
3.
REQUESTS the Director-General:
(1) to promote support for development of the WHO framework convention on tobacco
control and possible related protocols among Member States, organizations of the United
Nations system, other intergovernmental, nongovernmental and voluntary organizations, and
the media;
2
EB103.R11
(2) to complete the Organization’s technical work required to facilitate negotiations on the
WHO framework convention on tobacco control and possible related protocols;
(3) to convene the working group on the WHO framework convention on tobacco control
and the first meeting of the intergovernmental negotiating body based on progress achieved
by the working group;
(4) to provide the working group on the WHO framework convention on tobacco control
and the intergovernmental negotiating body with the necessary services and facilities for the
performance of their work;
(5) to facilitate the participation of the least developed countries in the work of the working
group on the WHO framework convention on tobacco control, in intergovernmental technical
consultations and in the intergovernmental negotiating body;
(6) to invite, as observers to the sessions of the working group on the WHO framework
convention on tobacco control and the intergovernmental negotiating body, representatives
of non-Member States, of liberation movements referred to in resolution WHA27.37, of
organizations of the United Nations system, of intergovernmental organizations with which
WHO has established effective relations, and of nongovernmental organizations in official
relations with WHO, who will attend the sessions of those bodies in accordance with the
relevant Rules of Procedure and resolutions of the Health Assembly.
Tenth meeting, 29 January 1999
EB103/SR/10
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EB103.RU
ANNEX
OUTLINE OF EXPECTED ACTIVITIES
January 1999 to May 2000 (completion of prenegotiation phase), and targets for negotiation and
adoption of the WHO framework convention on tobacco control and possible related protocols
(May 2000 to May 2003)
Milestones
Governing and
subsidiary bodies
Decision and actions by
governing and subsidiary bodies
Actions by the Secretariat
January 1999
Executive Board
• Recommend for adoption by the
Fifty-second World Health
Assembly the resolution
Towards a WHO framework
convention on tobacco control
After the 103rd session of the
Executive Board
• Disseminate information on the
process for developing the
framework convention
• For the Fifty-second World
Health Assembly, prepare
briefing document(s) on the
process
• Hold consultations with
Member States
May 1999
Fifty-second
World Health
Assembly
• Consider the draft resolution
Towards a WHO framework
convention on tobacco control
• Establish the intergovernmental
negotiating body and the
working group on the framework
convention on tobacco control
• Hold briefing sessions on the
framework convention during
the Fifty-second World Health
Assembly
After the Fifty-second World
Health Assembly
• Support intergovernmental
technical consultations on the
framework convention
• Facilitate participation of least
developed countries in the
process for developing the
framework convention
• Provide technical support
May 1999 to
January 2000
Working group on
the framework
convention
• Initiate preparation of proposed
draft elements of the WHO
framework convention on
tobacco control
• Convene the working group on
the WHO framework
convention on tobacco control
• Provide technical support
January 2000
Working group on
the framework
convention
• Submit progress report of the
working group on the framework
convention to the Executive
Board at its 105th session
• Consider the progress of the
working group
• Provide technical support
Executive Board
January 2000
to May 2000
Working group on
the framework
convention
• Continue work based on
direction from the Executive
Board
• Provide technical support
May 2000
Fifty-third World
Health Assembly
• Submit report of the working
group on the framework
convention to the Fifty-third
World Health Assembly
• Hold technical briefing during
the Health Assembly on
alternative negotiation
processes
May 2000
(target date)
Intergovernmental
negotiating body
• Hold the first organizational
session
• Convene the first meeting of
the intergovernmental
negotiating body based on
progress achieved by the
working group
• Provide technical support
May 2000 to
Intergovernmental • Negotiate the draft framework
May 2003
negotiating body
convention and possible related
(Target date
protocols
for adoption)
Note: Process and content will be driven primarily by Member States, but will also include input from bodies of
the United Nations system, other international, regional, or intergovernmental organizations, and
nongovernmental organizations.
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The FCTC: an accelerated work plan
Now that WHO has given a higher profile to global tobacco control, the Organization, in
conjunction with its Member States, will accelerate work on the FCTC. The development of the
FCTC represents the first time that WHO has exercised its mandate to develop a convention
under Article 19 of its Constitution, and therefore represents a major shift in its attitude to
international law as an important means of promoting public health (Taylor, 1992).' By exercis
ing its under-utilized potential to develop international instruments, WHO will be able to encour
age the development of national health legislation and, it is hoped, encourage the allocation of
more resources to tobacco control.
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With respect to the development of the FCTC, Dr Douglas Bettcher, Coordinator, FCTC Team,
said that it was impossible to exactly predict or map out a treaty-making process beforehand,
because the momentum of international law-making depended on the political will of sovereign
States. However, the following key milestones had been agreed by the WHO Cabinet as a broad
template for the FCTC process (Fig. 1).
FIG. 1. FCTC accelerated work plan
Technical
Technical consultations
(Sept. 1998 to June 1999)
Pre-negotiation
FCTC advisory working group
and national commissions
(May 1999 to May 2000)
Negotiation
Intergovernmental
negotiating committee
(May 2000 to May 2003)
I
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Adoption
World Health Assembly 2003
1998
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1999
2000
2001
U_
2002
-U
2003
Dr Bettcher stressed that the Vancouver meeting was a key stage in the development of the
FCTC. It was being held immediately before the WHO Executive Board considered the acceler
ated FCTC work plan and future steps in developing the convention at its 103rd session early in
1999. Therefore, the outputs of the meeting needed to provide key recommendations to WHO
Member States on policy issues of strategic importance. Towards that end, the participants
focused on making recommendations in the following areas:
1 Taylor, A.L (1992), "Making the World Health Organization Work: A Legal Framework for Universal Access to the Conditions for
Health, "in American Journal of Law and Medicine, XVIII, 331).
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• Public health issues which should be addressed in the FCTC;
• The essential roles of WHO headquarters and regional offices, Member States, regional and
international intergovernmental organizations, nongovernmental organizations and the me
dia in the development of the FCTC;
• The issues from a developing country perspective, and mechanisms to facilitate the active
involvement of developing countries in the pre-negotiation and negotiation phase of the
FCTC process.
SESSION 2
PUBLIC HEALTH AND INTERNATIONAL TOBACCO CONTROL
The tobacco epidemic is increasingly spread across international borders by a variety of means,
I including advertising/promotion and smuggling.The substantive cross-border issues the FCTC
process should address, most probably in protocols to the framework convention itself, formed
the focus of the first discussion.
Improving public health through the FCTC
Dr L. Joossens, (Centre for Research and Information for the Consumer Organisations, Brus
sels, Belgium) opened the substantive discussion of the FCTC by highlighting key considerations
for the convention and related protocols. He identified and described nine major areas of con
cern: price, taxation, smuggling, duty-free sales, advertising and sponsorship, Internet trade,
package design and labelling, tobacco-based agriculture, and information-sharing.
Harmonization of taxes, strict control on international tobacco transport, ending duty-free
tobacco sales, and the end of tobacco subsidies were all described by Dr Joossens as crucial
elements for the FCTC and its protocols. Further, he called for a global ban on tobacco advertis
ing; Internet controls; the creation and worldwide use of comparable, accurate and meaningful
test methods for cigarettes, and putting the results of tests in the public domain; and standard
ized package design. Finally, internationally comparable information should be collected and
disseminated to assist in the development of policies.
The dominant theme emerging during the discussion was how national and international
issues were to be separated. Several participants mentioned political feasibility in addition to
geography in defining what should or should not be approached in the FCTC and its protocols.
While the FCTC lends itself to issues which have an inherent international component, there are
no legal impediments to the Convention addressing issues that have up to now usually re
mained in the national sphere. The important role of international information-sharing, includ
ing information on issues that may continue to be controlled chiefly at the national level, was
stressed by several participants. The importance of adequately supporting the tobacco control
efforts of developing countries was also stressed.
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SESSION 3
WHO AND THE FCTC
A s the directing and coordinating authority on international health work, WHO clearly has a
r\ responsibility to address adequately a public health problem of the scale of that created by the
tobacco industry. This must include using all its authority as broadly and vigorously as necessary to
achieve its stated objective of the attainment by all peoples of the highest possible level of health. The
following section reviews the role of WHO in promoting the FCTC.
The development of the WHO framework convention
on tobacco control: principles of law and process
Professor Allyn Taylor, (Adjunct Professor, Johns Hopkins University School of Hygiene and Public
Health, Baltimore, USA) discussed principles of law and process with respect to the negotiation, adop
tion and entry into force of the FCTC. Specifically, she discussed three major areas: (1) the legal author
ity and constitutional responsibility of WHO to develop the FCTC for consideration by Member States;
(2) principles of legal process applicable to development of the FCTC; and (3) recommendations for
future action to further Member States' support for the adoption and ratification of the convention.
As called for by Member States of WHO in resolution WHA 49.17, the initiation of the develop
ment of the FCTC by the WHO Secretariat is consistent with the objectives, functions and powers of
WHO as set forth in its Constitution. In addition, the catalytic role of WHO in initiating the development
of the FCTC, as described in theTFI accelerated work plan, is consistent with the contemporary practice
of international organizations. International organizations increasingly play a leadership role in the
development and implementation of international law.
The broad scope of WHO's mandate to address global public health concerns vests the Organization
with the legal authority to serve as a platform for the development of binding treaties that potentially
address all aspects of tobacco control, national and transnational, as long as advancing human health is
the primary objective of such agreements. During the process of developing the treaty, WHO Member
States may ultimately choose to limit the scope of the treaty. Any such limitations on the potential scope of
the FCTC in addressing the tobacco pandemic are not mandated by WHO's Constitution.
Professor Taylor said that international law allowed considerable flexibility in the process by which
multilateral agreements are developed. In the absence of many binding international rules governing
the treaty-making exercise, international organizations have adopted a wide variety of strategies to
initiate, negotiate and conclude international agreements. The experiences of other international or
ganizations can serve as a model and guide to WHO as it develops an effective strategy to forge global
consensus for the FCTC and protocols. She emphasized the important role that a negotiations work
shop could play in considering the various strategic and legal issues relating to preparations for the
FCTC negotiations.
In response to questions, Professor Taylor explained the likely timing and nature of options that
would present themselves during the process. Two threads ran through much of the discussion: the
distinction between legal and policy considerations, and the high degree of flexibility inherent in the
treaty-making process.
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SESSION 4
THE SPECIAL CIRCUMSTANCES OF DEVELOPING COUNTRIES
omprising a majority of the world's population, a majority of the potential parties to the
x- FCTC, and a potential market of explosive growth for the tobacco industry, the developing
world clearly is key to the success of the convention. In keeping with that importance, the
Vancouver meeting began the process - which will continue in future meetings - of identifying
matters of particular concern to developing countries through the perspective of some of them.
The FCTC from a developing country perspective
In an overview and critique of a paper prepared by Mr Lovkesh Sawhney, (Advocate, New
Delhi, India) Dr Yussuf Saloojee, (National Council Against Smoking, Johannesburg, South Africa)
reaffirmed not only the staggering scope of the tobacco pandemic in the developing world, but
also the growing gravity of the problem as tobacco's spread shifted from developed to develop
ing countries. The main difficulties and issues faced by developing countries in implementing
effective tobacco control measures, in Mr Sawhney's opinion, are: the economic and social impli
cations, political realities, smuggling issues, the limitations of regulatory and enforcement mecha
nisms, and the uncertain efficacy of advertising bans.
In the discussion, there was a spirited rebuttal of some of Mr Sawhney's conclusions, par
ticularly his views on the inapplicability of lessons from developed countries on price elasticity
and the effect of advertising restrictions to developing countries. However, the statement was
helpful in placing many of the tobacco industry's traditional objections to tobacco control on the
table, and in describing the political realities faced by a country such as India with a large bidi
industry employing many people and the tobacco trade in general.
Mr Sawhney's suggested solutions to some developing country problems included the in
volvement of NGOs and the judiciary, and the establishment of an international support fund for
developing countries.
Are developing countries targets
of the tobacco industry?
As described by Professor E. Dagli, (Mamara University Hospital, Istanbul, Turkey) many
developing countries, which already lack basic human needs such as food and water supplies,
have had their plight exacerbated by the aggressive marketing strategies of the tobacco industry.
In reviewing the marketing strategies used by the tobacco industry in the past two decades in
Turkey, and examining the consequences of such marketing there, she drew lessons for other
developing countries that had not yet sustained as severe an invasion by the global tobacco
companies. Professor Dagli described tobacco industry tactics in Turkey, including: denial of
health evidence; sponsoring of diversionary scientific research; large investments in promotion
and advertising; interference with national public health laws; the creation of joint ventures with
national monopolies; and persuading the Government of the risks of smuggling.
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Tobacco Free Initiative: the Bangladesh perspective
Though written with reference to the Tobacco Free Initiative, not the FCTC perse, the paper
of Dr K. Rahman, (Counsellor, Permanent Mission of the People's Republic of Bangladesh to the *
United Nations Office, Geneva, Switzerland) provided insights into the perspectives and prob
lems of tobacco control in Bangladesh.
Particularly for the young, the poor and women, tobacco is an increasing health problem in
Bangladesh. Tobacco industry publications refer to Bangladesh with.optimism, in large because
of its annual cigarette sales growth rate of 6.4%. Moreover, any foreign investment is often
viewed as good, even without a cost/benefit analysis. In general terms, these features seem to
be common to many developing countries.
Dr Rahman described public awareness campaigns, NGO action, crop diversification, and
bringing the religious community into the issue as elements necessary for tobacco control in
Bangladesh. In all of these he echoed a view raised frequently in the Vancouver meeting: that
WHO and other United Nations agencies should be facilitating these necessary domestic to
bacco control efforts.
Dr Rahman proposed a joint study by WHO, the Food and Agriculture Organization of the
United Nations (FAO), the United Nations Conference on Trade and Development (UNCTAD) and
World Bank on the economic aspects of tobacco growing and the need for assistance to devel
oping countries for a crop diversification programme in order to discourage tobacco cultivation.
He also favoured putting gradual restrictions on the advertisement of tobacco in both public and
private media as well as increased involvement of the healthcare community in anti-tobacco
campaigns.
SESSION 5
THE ROLE OF NGOS IN SUPPORTING FCTC
n
Though ultimately the prerogative of States, the political process of advancing the FCTC, both
I internationally and domestically, is likely to involve many actors including, in a central role,
NGOs. The diversity, presence and credibility of many NGOs around the world put them in a
unique position to help to shape the debate and overcome the inevitable obstacles the tobacco
industry and its allies will place before the FCTC.
Mobilizing NGOs behind the FCTC:
experiences from infant formula, landmine
and environmental codes/conventions
Ms Kathy Mulvey, (Campaign Development INFACT, Boston, USA) described her experi
ences, and those drawn from colleagues in other organizations, on the involvement of NGOs in
the processes leading to the breast-milk substitute, landmine and environmental codes and
conventions. In her opinion, NGO involvement resulted in stronger treaties with shorter time
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lines. As the participants endorsed strong NGO participation, issues of coordination of that
participation, particularly matters of timing and resources, were key. It was emphasized that
only NGOs could catalyse and coordinate an NGO network or coalition. The essential independ
ence of NGOs meant that they were less restricted by political feasibility than governments and
WHO. That allowed them to set visionary goals, change the public climate, and expand the
horizons of what is politically feasible.
NGOs' primary roles, in Ms Mulvey's view, were the establishment of a coalition and com
munication network, setting a bottom line on expectations and standards, providing technical
expertise on issues, monitoring and exposing industry abuses, and in some instances putting
direct economic pressure on the industry. There was general agreement that the key relationship
between WHO and NGOs centred on information-sharing.
Ms Mulvey pointed out that the framework convention was not just a legal document; it
was also a political document. The public climate was what made action politically feasible. In
that regard, the NGOs and the media were crucial. The more visionary the goals, the more
motivating they were to the public. The mobilization of NGO support for the FCTC had the
potential to catalyse the development and negotiation of the FCTC, as had been demonstrated
with other recent international instruments.
Finally, the meeting discussed the participation of the tobacco industry in the FCTC process.
The majority were strongly of the opinion that the industry and it front groups should not partici
pate in the guise of an NGO, as they would probably already be making their views known
through several national governments. To paraphrase one participant, most industries had a
reason to cooperate with States seeking to regulate them: the protection of their legitimate
operations. The tobacco industry, by comparison, has no reason to assist the public health
objectives of the FCTC, as the industry's operations were antithetical to the objectives propelling
the convention forward. It was stressed that tobacco industry involvement, direct or indirect,
would result in loophole-ridden or pre-emptive laws, which could be worse than no laws.
SESSION 6
OPTIONS FOR THE DEVELOPMENT OF THE FCTC
Though the public health rationale for the FCTC is evident, in the end the concerns and
ideas need to come together in a workable legal structure which forms the text of the conven
tion. The following presentations addressed this issue, drawing in part on lessons from prior
framework conventions in other fields. They were followed by a joint discussion.
The framework convenfion/protocol approach: the
experience of international environmental regimes
The framework convention/protocol approach was described by Professor Daniel Bodansky
(University of Washington, Seattle, USA) as one that proceeds incrementally, beginning with a
framework convention that establishes a general system of governance for an issue area, and
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then developing more specific commitments and institutional arrangements in protocols. This,
approach has had considerable success in the environmental arena. Examples were drawn from
numerous environmental agreements, including the United Nations Framework Convention on
Climate Change and the Vienna Convention for the Protection of the Ozone Layer.
In Professor Bodansky's view, States tended to be willing to join a framework convention
because it did not entail significant substantive commitments. But, once created, the regime
could take on a momentum of its own, by providing a forum for discussions, serving as a focal
point for international public opinion, creating trust among participants, and building political
and scientific consensus.
Elements of a framework convention might include:
• A statement of the convention's overall objective and guiding principles;
• Basic obligations, including commitments to take national measures to address the relevant
problem, to exchange information, to cooperate in scientific research, and to submit periodic
reports;
• Institutions, including, at a minimum, a regular conference of the parties and a secretariat,
and also possibly a scientific advisory body, an implementation body, and a financial mecha
nism;
• Mechanisms to review implementation, promote compliance, and resolve disputes;
• A law-making process for the adoption of more specific commitments, usually in protocols.
The structure of framework treaties: considerations
for an international FCTC
Mr Eric LeGresley described consistencies in structure and approach among existing frame
work treaties, and explained how these approaches might be translatable to a tobacco context
because such treaties usually dealt more with procedural than substantive issues.
He noted that existing framework treaties generally included six major parts, each address
ing characteristic concerns:
• A preamble to set the tone, and explain the raison d'etre of the treaty in a manner designed
to make the legal and political case for action, as well as inspire support;
• A section dealing with the core elements and defining broad obligations, many of which are
likely to be refined and elaborated upon in subsequent protocols;
• A section defining institutional arrangements which create the necessary infrastructure to
enable the framework/protocol system to be implemented and evaluated, and to grow to its
full potential;
• A broad grouping of issues concerned with relations with others, dealing with the positive
interrelationships the treaty seeks to engender and, through arrangements for the resolution
of disputes, the negative relationships that inevitably arise;
• The final provisions, which deal with matters necessary to make the document function legally.
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Joint discussion
The discussion dealt primarily with process issues, including the relationship between protocols
and the framework convention, the emergence of new protocols as new knowledge or new
political support materialized, the relationship of regional treaties to a global one, and the
possible location of the secretariat. The political difference between non-binding State support
for a World Health Assembly resolution and that same State's binding acceptance of a compara
ble provision within the FCTC or a protocol was discussed.
A principal concern of many participants was the incorporation of mechanisms to ensure
compliance by those regulated and adequate monitoring. The significant input that the public
health community could make into some parts of the FCTC (preamble, principles, core elements
etc.) and the less substantial input it could contribute to others (institutions, final provisions,
etc.) was discussed. The participants endorsed the view that the experience of environmental
framework treaties was one - admittedly important - example that should be studied in tobacco
control, but that all options and previous experiences should be reviewed. Finally, there was
broad agreement that the FCTC needed to begin very strong from a public health standpoint,
and at an early stage establish the primacy of basic health principles, which should be adhered
to throughout the process. >
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Plan of Action
Working Group Outputs
WORKING GROUP 1
ACCELERATING THE WORK OF THE FCTC AND MOBILIZING SUPPORT
I\ /I oving the FCTC forward will be a multifaceted effort, involving many different actors.
IVI Working Group 1 produced a succinct set of recommendations covering a wide array of
desirable steps and approaches.
General
• The Working Group endorsed the FCTC Accelerated Work plan.
• The first priority is political mapping of likely support and opposition to the proposed convention.
• A WHO web site can play a key role in disseminating information and mobilizing support.
Political mapping
• WHO should draw on a wide variety of official and informal sources of information regarding
likely support and opposition to the proposed framework convention, including bilateral con
sultations, intergovernmental meetings, and NGO contacts.
• WHO should send questionnaires to Member States to gather background information on
national legislation, and on what international regulatory measures governments would find
useful.
• WHO should involve its regional and local representatives closely in the questionnaire process
and should use other sources of information to assess questionnaire responses.
Negotiations workshop
• The working group endorses the convening of a negotiations workshop.
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• The primary participants in this workshop should be TFI staff, Member States and the WHO
legal counsel.
• Participants should include representatives of key allies, a few public health people, and rep
resentatives of the United Nations and specialized agencies with extensive negotiations ex
perience (e.g., the International Labour Organization (ILO), the United Nations Environment
Programme (UNEP), FAO, and the Office of the United Nations High Commissioner for Human
Rights and the World Trade Organization (WTO).
New Delhi meeting
• WHO should identify key developing country NGOs, notify them of the. meeting (October
1999, New Delhi, India) and if possible, invite them to participate.
• Government experts should be invited to attend the meeting.
Technical workshops
• WHO should convene technical workshops on specific topics such as trade, finance, advertis
ing, protection of children and women, and indigenous peoples during the pre-negotiation
stage.
• Workshops could be sponsored by interested governments.
• Participants should include government experts, representatives of international organiza
tions, and NGOs, and academics
Mobilizing NGO support
• NGOs need to play an important role in development of the FCTC.
• NGOs should include not only those active in tobacco control, but also other groups, including
NGOs focusing on women, children, indigenous groups, and so on.
• WHO cannot coordinate these NGOs, but it can facilitate their involvement in the process.
• NGOs should form an international coalition.
• WHO needs to develop a strong statement of the purpose of the FCTC in order to mobilize
NGO support (NGOs need something to rally round).
FCTC working groups
• National working groups could play a useful role in mobilizing support.
• WHO lacks the authority to establish such groups.
• WHO regional offices, and regional offices of other organizations, could play an important
role in promoting the establishment of national groups.
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Draft elements of the convention
• WHO should convene an expert group to develop elements of a draft framework convention,
with annotation.
• Draft elements of the convention should be completed in 1999, for consideration by an inter
governmental meeting in 2000.
Fund for developing country participation
• The Executive Board should authorize the establishment of a trust fund to facilitate the par
ticipation of developing countries in the preparation of the framework convention.
Intergovernmental meetings
• Intergovernmental meetings should be convened beginning in early 2000, to mobilize sup
port for framework convention negotiations.
WORKING GROUP 2
ADDRESSING THE NEEDS OF DEVELOPING COUNTRIES
The pressing need to consider the circumstances of developing countries was reflected not
I only in several presentations, but also in Working Group 2, which refined and further elabo
rated upon the issues raised in these discussions, and others.
• The characteristics of developing countries from the aspect of tobacco control:
- Position as targets of the tobacco industry;
- Lack of priority of tobacco as public health demand;
- Lack of research and data;
- Deficiency in advocates and in sources of funding;
- Lack of enforcement capacity;
- Deficits in education and information;
- Limited consumer movement;
- Perceived economic dependence on tobacco production and taxation.
• There are great variations in the strength of response in developing countries to the tobacco
threat.
• Obstacles to tobacco control in developing countries:
- Conflicting interests of ministries;
- Lack of involvement of health ministries and a weakness of the health sector;
- Lack of information of parliamentarians and opinion leaders;
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| Framework Convendon on Tobacco comot
- Government-owned tobacco industry;
- Influence of the tobacco industry on political power centres;
- Lack of, or weak, NGO movement;
- Lack of up-to-date local scientific data and research.
• Solutions:
- Mobilize the support of the media, trade unions and other consumer groups;
- Improve surveillance and monitoring;
- Develop data;
- Provide technical assistance on drafting and implementing legislation, political advocacy,
education, surveillance and litigation where appropriate;
- Create a focal point on tobacco staffed with full-time personnel;
- Provide technical support for capacity-building and training trainers, and assistance for
agriculture;
- Make tobacco a priority for the government by linking it to other health problems, and
build it into the primary care system;
- Prepare information leaflets for various countries;
- Ensure full and vigorous participation of developing countries in all stages of the FCTC
process, including participation in the New Delhi meeting (October 1999) and involving
the WHO regional offices and NGOs;
- Mobilize support from regional intergovernmental organizations and regional voluntary
associations, and encourage support for the FCTC from regional groupings of countries.
• Funding:
- Adequate funds are required from domestic and international sources to support realiza
tion of the FCTC, and to finance the activities of its secretariat;
- In order to provide sustained funding, an amount equal to at least 1 % of tobacco taxes in
each country should be allocated to tobacco control, including FCTC activities;
- Financial and technical support from international agencies should be enlisted;
- Increased funding for tobacco control and capacity-building should be sought from pri
vate entities, including foundations, professional associations, corporations, trade asso
ciations, and universities;
- There should be created within the FCTC a multilateral trust fund to support its realiza
tion, along with incentives for implementation of the convention and protocol provisions.
• Recommendations:
- WHO should establish and implement a plan to ensure the full and vigorous participation
of developing countries in the convention /protocol process;
- WHO, in collaboration with international agencies and NGOs, should develop and imple
ment a plan for technical and financial support to national governments for capacity
building on tobacco control;
- WHO should solicit funding from all governments, appropriate private agencies and inter
national organizations and provide the establishment, including arrangements within the
FCTC, of a multilateral trust fund for achievement of global tobacco control;
- Sustainable tobacco control in all Member States, which is essential for the FCTC process,
28
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Towards an Integrated Plan of Action |
requires a contribution of the equivalent of at least 1 % of tobacco taxes to be allocated to
domestic and international tobacco control;
- The objective of the FCTC should have a strong public health focus, including reference to
the particular problems of developing countries;
- At least three protocols should be submitted simultaneously with the FCTC, to all coun
tries, covering, for example, the control of smuggling, protection of children, and main
taining current low smoking rates among women in many developing countries.
.:/L. ;■
WORKING GROUP 3
THE PUBLIC HEALTH CONTEXT
To ensure that attention to matters of process did not cause the meeting to lose sight of the
I underlying objectives the FCTC is meant to serve, Working Group 3 endeavoured to clarify
and reiterate the essential health issues and implications by proposing a draft preamble and
principles, together with recommended protocols and key elements.
Draft preamble and principles
Preamble
1. Whereas tobacco industry products are addictive and are lethal when used as intended;
2. Whereas tobacco products are the cause of unparalleled morbidity and mortality; and recog
nizing that elimination of tobacco product use could be one of the most important sources of
improvement of public health; and
3. Whereas international cooperation could greatly facilitate the ability to reduce tobacco prod
uct use and improve public health;
Principles
1. Whereas everyone has the right to be fully informed with respect to the health hazards and
health impact of tobacco use;
2. Whereas nonusers of tobacco products are entitled as a basic right to be free from the sec
ondary effects of tobacco use;
3. Whereas it is in the interest of public health to assist those addicted to tobacco products to be
free from addiction; and
4. Whereas children have the right to reach the age of responsibility free of an addiction to
lethal and addictive products.
29
| Framework Convintion on Tobacco control
Recommended protocols and key elements:
Protect children and adolescents from exposure to and use of tobacco
•
•
•
•
•
Advertising, promotion, Internet, entertainment;
Access of children and youth;
Child labour;
Recreation;
Information on effectiveness of school programmes and mass media.
Prevent and treat tobacco dependence
•
•
•
•
Advertisements, packaging, warnings;
Cessation: role of health services and health professionals;
Information on effectiveness of low-cost cessation methods;
Regulation of nicotine.
Tobacco smuggling
• Licensing of Vendors;
• Linkage to Customs groups and laws;
• Duty-free sales;
• Warnings;
• Pricing/taxation.
Promote healthy tobacco-free environments and economies
• Environmental tobacco smoke (using a human rights approach);
• Agriculture: stop subsidies and use them to fund alternatives;
• Research to support transition to a tobacco-free economy: document the impact on the
environment.
Strengthen women's leadership role in tobacco control
• Women of Africa and Asia as desired future role models;
• Advertisements, fashion complicity, entertainment;
• Constituents;
• Research on gender-sensitive interventions: pregnancy, young women, healthy ageing.
Protect vulnerable communities
•
•
•
•
Targeted strategies;
Sharing resources for capacity-building;
Solidarity with groups;
Protect socially vulnerable groups.»
30
T
Final Recommendations
from the Meeting
The meeting participants, after extensive discussion and careful deliberation, were able to
I synthesize their collective views into the following statement.
The role of WHO in promoting
a framework convention
1. WHO's Member States have lent their support to drawing up an international treaty to reduce
damage to health caused by tobacco products. The World Health Assembly has determined
that a framework convention-protocol approach is the most appropriate vehicle to accom
plish the task.
2. WHO has clear legal and moral authority to convene working groups to propose key elements
of the convention for consideration by Member States, and to take responsibility for support
ing long-term implementation.
3. As there is already a broad consensus based on WHO Resolutions calling for a framework
convention to limit damage caused by tobacco, WHO should accelerate the work on the first
draft of key elements of the convention, and one or more accompanying protocols, according
to the accelerated work plan.
4. The WHO Secretariat should report to the Executive Board and World Health Assembly on the
progress made on the convention process in 1999. The Board should be asked to authorize
the Secretariat to convene an expert group to develop draft elements of the convention.
5. Draft elements of the convention and, if appropriate, relevant protocols should be completed
for consideration by intergovernmental meetings in early 2000 and eventual submission to
the World Health Assembly in 2000.
Structure and tontents of the tonvention and prototols
6. The convention should consist of the following parts that may be composed of varying ele
ments, depending on the structure of the convention:
31
| Framework Convention on Tobacco control
- preamble;
- core elements of guiding principles, general objectives and obligations;
- implementation mechanisms, law-making processes;
- institutional elements;
- final provisions.
7. The preamble should include a clear statement of the scale of the tobacco problem from the
health point of view and the magnitude of the risks of tobacco use, the role of the global
tobacco industry, an explanation of the need for an international instrument, the authority of
WHO to facilitate the development of a convention on tobacco control, as well as a renewed
commitment to the key elements of a comprehensive tobacco control policy at national and
international levels.
8. The guiding principles of the convention should encompass both national and transnational
measures, including the following:
- Tobacco is an important contributor to inequity in health in all societies;
- As a result of the unique nature (addiction, health damage) of tobacco products, normal
trade practices are not applicable;
- The public has a right to be fully informed about the health consequences of using to
bacco products;
- The health sector has a leading responsibility to combat the tobacco epidemic, but suc
cess cannot be achieved without the full contribution of all sectors of society.
9. A concise and strong statement on the purpose of the convention is essential to clarify its
importance and to mobilize support. The substantive thrust of the convention should be con
tained in a limited number of general objectives.
10. Proposed general objectives include the following, among others:
- Protecting children and adolescents from exposure to and use of tobacco products and
their promotion;
- Preventing and treating tobacco dependence;
- Promoting smoke-free environments;
- Promoting healthy tobacco-free economies, especially stopping smuggling ;
- Strengthening women's leadership role in tobacco control, especially maintaining the low
smoking prevalence rates of women in many developing countries;
- Enhancing the capacity of all Member States in tobacco control and improving knowledge
and exchange of information at national and international levels;
- Protecting vulnerable communities, including indigenous peoples.
11 .The convention should promote sustainable tobacco control by requiring a substantial con
tribution from tobacco taxes to be allocated to domestic and international tobacco control.
12.Under the convention, parties will be obliged to take appropriate measures to fulfil the gen
eral objectives.
32
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Final Recommendations from the Meeting |
13. The convention should provide for convening regular meetings of the parties and emphasize
responsibility of the WHO Secretariat for serving as the secretariat for the convention.
14. The convention should address the following issues:
- National reporting on the tobacco situation and tobacco control measures in each country;
- Encouragement of interactions among all parties and non-parties concerned;
- Definition of the relationship between the Convention and other international instru
ments.
*
15. It is important that one or more protocols be adopted concurrently with the framework
convention. Depending on the political will of Member States, subject matters of such protocols
may include:
- protecting children and youth from tobacco products,
- maintaining the low level of smoking among women in many developing countries;
- controlling smuggling.
Special support for developing countries
16. Some developing countries have shown their capacity to deal with important aspects of the
tobacco problem, but the convention must clearly empower them to address the public health
disaster in ways most suitable for them. Global trade treaties to protect public health must
be used to their full extent.
17. The tobacco economy of the developing countries is changing rapidly in ways that must be
carefully monitored. An authoritative study, especially of agricultural aspects, carried out
jointly by international bodies is essential. Documenting the impact of the tobacco industry
and its products by country will help to develop countermeasures to protect the public's
health.
18. Technical assistance on developing current data on the health, economic and environmental
impact of tobacco, on education and information, on drafting legislation and regulations, on
litigation, where appropriate, and on advocacy and lobbying should be assured.
19. There is a pressing need to secure financial assistance for the developing countries to imple
ment the convention and to build capacity to participate in global and national activities on
tobacco control. Therefore, provision should be made in the convention for the establishment
of a multilateral trust fund, with contributions from governments, international agencies and
private sources.
Promoting adoption of the convention
20. Political mapping should be carried out to identify and inform supporters of the convention
among the Member States and nongovernmental organizations. This procedure should en
sure that support can be generated in the most efficient way.
33
| Framework Convention on Tobacco control
21. The WHO Tobacco Free Initiative should convene, at an early date in 1999, an international
negotiation workshop to consider legal and strategic issues in relation to the development of
the convention.
22. Governments should sponsor technical workshops on topics such as trade, finance, advertis
ing and promotion, and protection of children, women, indigenous peoples, and other vul
nerable populations during the pre-negotiation phase. All meetings and workshops related
to the convention process should be very focused and outcome-oriented to accelerate the
negotiation and adoption process.
23. The WHO Secretariat should ensure, with the support of Member States, regional and country
offices, collaborating centres and other actors, the development of publicity and information
materials, including a toolkit of information and creation of appropriate Internet sites.
24. Developing countries will require financial and technical assistance to participate in the proc
ess of formulating and promulgating the convention. WHO should establish a separate
multilateral fund for this purpose. Some countries have already promised new financial
support to the process of making the convention.
25. During the process of negotiating the convention, public health goals shall be emphasized. >
34
-Jffl
Annex 1
Conference Participants
Visitors to Meeting
ABLOG-MORRANT Kelly • BC Lung Association
ANDERSON Kimberly •Ministry of Attorney General, Government of British Columbia
BLATHERWICK Dr. John •Vancouver-Richmond Health Board
DAY Linda •Aboriginal Health Association
ETHERIDGE Brian • Ministry of Attorney General, Government of British Columbia
British Columbia Staff
Conference staff
BARTON Simon • Ministry of Health, Government of British Columbia
BERUBE Sylvie • Health Canada
BOS Iris • Ministry of Health, Government of British Columbia
CANITZ Shelley • Director, Tobacco Strategy, Ministry of Health, Government of British Columbia
CARTER Connie • Ministry of Health, Government of British Columbia
EVE Donelda • Manager, Projects and Liaison, Tobacco Strategy, Ministry of Health,
Government of British Columbia
EWING Patrick • Ministry of Health, Government of British Columbia
HORN Hannah • Ministry of Health, Government of British Columbia
KEELOR Sean • Ministry of Health, Government of British Columbia
LANGFORD Donna • Ministry of Health, Government of British Columbia
LOEB Megan • Ministry of Health, Government of British Columbia
McCAFFREE Jina ♦ Ministry of Health, Government of British Columbia
MOON Anne • Ministry of Health, Government of British Columbia
NYBERG Del • Ministry of Health, Government of British Columbia
PHILLIPS John • Director, Tobacco Reduction Programs, Ministry of Health, Government of British Columbia
WESTON Dale •Government of British Columbia
Observers
PRIDDY Hon. Penny •Government of British Columbia
PRAZNIK Hon. Darren •Government of Manitoba
BECKETT Regina •Government of Alberta
BERGER Thomas • Berger & Nelson
CALLARD Cynthia • Physicians for a Smoke-Free Canada, Ottawa, Canada
D'CUNHA Colin • Government of Ontario
GILBERT Dr. John • University of British Columbia
GORMAN •Diane, Health Canada, Government of Canada
KROEKER Lori •Government of Manitoba
35
| Framework Convention on Tobacco control
KELLY Doug • First Nations Summit, Health Committee
LAFFERTY Vicki • Government of the Northwest Territories
LOUGHEED Andrew •Government of Manitoba
MACGREGOR Lesley • Heart and Stroke, Foundation of BC and Yukon
MASSE Richard • Government of Quebec
MEARNS Michael •Aboriginal Health Association of BC
MYERS Elliott • Bull, Housser & Tupper, Vancouver, BC
O'HARA James III •Washington, USA
ROLLINS Darcy •Government of Manitoba
SACHDEVA Mona •Canadian Cancer Society
THOMAS Viola •United Native Nations
WEBSTER Daniel •Bull, Housser & Tupper, Vancouver, BC
UNGURAIN Merv • Government of Nova Scotia
WHO Delegates
BASCHTodd •Boston, USA
DAGLI Elif • Istanbul, TURKEY
DURHAM Gillian •Wellington, NEW ZEALAND
HAGLUND Margaretha •Stockholm, SWEDEN
HIRSH Albert • Paris, FRANCE
LARKIN Michelle •Washington, USA
MAHOOD Garfield •Toronto, CANADA
MOCHIZUKI-KOBAYASHI Yumiko .Tokyo, JAPAN
NATHAN Rosa • Atlanta, USA
PIHATapani •Brussels, BELGIUM
RAHMAN Khalil •Geneva, SWITZERLAND
ROGERS Byron •Ottawa, Canada
ROEMER Ruth • Los Angeles, USA
RYAN John .LUXEMBOURG
SALOOJEE Yussif • Johannesburg,SOUTH AFRICA
SLAMA Karen • Paris, FRANCE
RITTHIPKAKDEE Bung On • Bangkok, THAILAND
WISEMAN Gloria .Ottawa, CANADA
VIANNA Cristine • Rio de Janeiro, BRAZIL
WALBURN Roberta .Minnesota, USA
ZATONSKI Witold .Warsaw, POLAND
WHO Staff and WHO Temporary Advisers
BETTCHER Dr Douglas .Geneva, SWITZERLAND
BODANSKY Dan .Seattle, USA
BURCI Gian Luca •Geneva, SWITZERLAND
COLLISHAW Neil .Geneva, SWITZERLAND
JOOSENS Luk .Brussels, BELGIUM
LEGRESLEY Eric .Geneva, SWITZERLAND
MULVEY Kathy .Boston, USA
TAYLOR Allyn. Maryland, USA
YACH Dr Derek • Geneva, SWITZERLAND
36
T
Annex 2
Conference Final Programme
Meeting Objectives
The preparation of an Framework Convention on Tobacco Control (FCTC) is a process driven by the need
to improve global public health, which also represents the primary theme of this meeting. The main
objectives of the meeting are:
• To discuss/recommend how public health might be improved through the development of the FCTC;
• To consider the role of WHO in the development of an international strategy for tobacco control;
• To examine what issues and approaches from a developing country perspective need to be considered
in the development of the FCTC;
• To consider the role of NGOs in mobilizing support behind the FCTC;
• To consider possible options for development of the Framework Convention.
Conference Final Programme
Wednesday, 2 December 1998
08h30 - 09h30
Registration
09h30- 12h15
Morning Session
Part 1 (Open to media)
09h30 - 09h35
Opening and Welcome
Moderator: Dr John Blatherwick, Medical Health Officer, Richmond
09h35 - 09h45
Welcome Address: Honorable Penny Priddy, Minister of Health,
Government of British Columbia
09h45 - 09h50
Welcome Address: Ms Diane Gorman, Regional Director General West, Health Canada
09h50 - 10h20
Context and new opportunities
WHO's new Tobacco-Free Initiative (TFI):
Presenter: Dr Derek Yach, Project Manager, TFI, World Health Organization
Framework Convention on Tobacco Control (FCTC): An Accelerated Work Plan
Presenter: Dr Douglas Bettcher, Coordinator WHO FCTC, World Health Organization
10h20 - 10h45
Coffee break
37
/'anarlaO
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tnin'iinn
fT^|
| Fbook Convention on Tobacco control
10h45- IlhOO
Group Photograph and Discussion
IlhOO- 12h15
Part 2 (Closed to Media)
Improving Public Health Through the FCTC
Presenter: Mr Luk Joossens
Moderator: Dr Gillian Durham
12h15-14h30
Lunch sponsored by Bull, Housser and Tupper
Lunch Session: Address by British Columbia=s legal team (discussion to follow)
Moderator: Ms Roberta Walburn
Audience: WHO delegation and observers
(Closed to the media)
14h30 - 17h30
Afternoon Session
14h30 - 15h45
The Role of WHO in Development of an International Strategy
for Tobacco Control
Presenter: Professor Allyn Taylor
Moderator: Ms Rose Nathan
15h45 16h15
Coffee Break
16h15 - 17h30
Mobilizing NCOS behind the FCTC: experiences from infant formulae,
landmines, and environmental codes/conventions
Presenter: Ms Kathy Mulvey
Moderator/discussant: Ms Karen Slama
18h30
17h00
21h00
Board buses outside hotel - drive to Salmon House
Dinner - Salmon House, West Vancouver
Dinner hosted by the Ministry of Health, British Columbia
Board buses - drive back to hotel
09h30 - 12h30
Morning Session
09h30 - 10h30
Panel Presentation:
Framework Convention/Protocol Approach: Experience of Environmental Regimes
Presenter: Professor Daniel Bodansky
The Structure of Framework Treaties: Considerations for an International
Framework Convention on Tobacco Control
Presenter: Mr Eric LeGresley
Moderator/discussant: Mr John Ryan
10h30 - IlhOO
Coffee Break
IlhOO- 12h15
Discussion
Moderator: Mr John Ryan
38
Y
Conference Final Programme |
12h30 - 14h30
Lunch hosted by the British Columbia Ministry of Health
Indigenous Tobacco Use
Speaker: Dr Jeff Reading
Moderator: Dr Karen Slama
14h30 - 17h3O
Afternoon Session
14h30 - 15h45
Issues and approaches from a developing country perspective
Presenter: Professor Elif Dagli and Dr Khalil Rahman
Moderator/discussant: Dr Yussef Saloojee
15h45 - 1630
Coffee Break
16h30 - 17h30
FCTC Working groups
Introduction to Working Group Sessions (16h00-16h 15)
Working Group 1: Accelerating FCTC work and mobilizing Support
(facilitator: Professor Daniel Bodansky)
Objective:To propose essential roles of WHO Headquarters and regional offices,
Member States, regional/international intergovernmental organizations,
non-governmental organizations, and the media in the development of the FCTC.
Working Group 2: Addressing the needs of developing countries
(facilitator: Professor Elif Dagli)
ObjectiveJo define issues from a developing country perspective, and to consider
mechanisms to facilitate the active involvement of developing countries in the pre
negotiation and negotiation phases of the FCTC process.
Working Group 3: The public health context
(facilitator: Ms Margaretha Haglund)
Objective:To identify the key public health issues which should be addressed in the FCTC.
18h30
Board buses outside hotel - drive to .University of British Columbia
Woodward IRC, Lecture Hall 6
2194 Health Sciences Mall
19h00 - 20h30
Panel Discussion on issues regarding advertising and promotion
University of British Columbia
Panellists: Mr Luk Joossens, Ms Kathy Mulvey, Mr Richard Pollay
Moderator: Dr Derek Yach
Audience: WHO delegation, observers, invited guests from British Columbia NGOs
and the academic community
(Open to media coverage and public)
20h30-21h30
Private Reception Cecil Green Park, UBC WHO delegates/observers
21 h45
Board buses - drive back to hotel
39
| Framework Convention on Tobacco control
Friday, 4 Detember 1998
09h00 - 16h00
Morning Session
09h00 - Wh30
Working Group 1: Accelerating FCTC work and mobilizing support
Working Group 2: Addressing the needs of developing countries
Working Group 3: The public health context
1Oh3O - 1Oh45
Coffee Break
10h45 - 12h00
Working Groups (Report Back to Plenary)
Noon
Media session
Professor Allyn Taylor, Dr Derek Yach, Dr Douglas Bettcher
12h00 - 14h00
Lunch
14h00 - 15hOO
Afternoon Session
14h00 - 16h00
Synthesis and Discussion of Recommendations
Facilitators: Dr Tapani Piha, Professor Ruth Roemer
Meeting Closing
*
40
•an/nQ/oa
I
1^*' I
1__ |
iye
WHO/NCD/TFI/99.7
Original: English
Distr.: General
i
Framework Convention
on Toha(to Control
Report of the WHO Meeting
of Public Health Experts
2-4 December / 998
Vancouver, British Columbia, Canada
Meeting Hosted by the Government of British Columbia
Tobacco Free Initiative
World Health Organization
^British
Columbia
___L
I
|
I
//
obacco control cannot succeed solely
through the efforts of individual govern
ments, national NGO's and media advocates.
We need an international response to an international
problem. I believe that response will be well encapsu
lated in the development of an International Frame
work Convention."
Dr Gro Harlem Brundtland
Seminar on Tobacco Industry Disclosures,
WHO, Geneva, 20 October 1998
is?
•■i&aa
rr i
i
I
L2ZL
Contents
Preface
7
Remarks by the Hon. Penny Priddy, Minister of Health and
Minister Responsible for Seniors, Government of British Columbia
9
Executive Summary
11
Introduction
13
Advancing the framework convention
15
15
15
16
17
17
18
Session 1: TFI overview and the FCTC accelerated work plan
The Tobacco Free Initiative
The FCTC: an accelerated work plan
Session 2: Public health and international tobacco control
Improving public health through the FCTC
Session 3: WHO and the FCTC
The development of the WHO framework convention on tobacco control:
principles of law and process
Session 4: The special circumstances of developing countries
The FCTC from a developing country perspective
Are low income countries targets of the tobacco industry ?
Tobacco Free Initiative: the Bangladesh perspective
Session 5: The role of NGOs in supporting the WHO FCTC
Mobilizing NGOs behind the FCTC: Experiences from infant formula,
landmine and environmental codes/conventions
Session 6: Options for the development of the FCTC
The framework convention/protocol approach: the experience of international
environmental regimes
The structure of framework treaties: considerations for an international FCTC
Joint discussion
Towards an integrated plan of action: Working Group outputs
Working Group 1: Accelerating the work of the FCTC and mobilizing support
Working Group 2: Addressing the needs of developing countries
Working Group 3: The public health context
Final recommendations from the meeting
The role of WHO in promoting a framework convention
Structure and contents of the convention and protocol
Special support for developing countries
Promoting adoption of the convention
Annex 1. Conference Participants
Annex 2. Conference Final Programme
Annex 3. Conference Background Statement
18
19
19
19
20
20
20
21
21
22
25
25
27
29
31
31
31
33
33
35
37
41
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Prefate
The issue of the report of the Framework Convention on Tobacco
I Control: Meeting of Public Health Experts held in Vancouver, British
Columbia, Canada, from 2 to 4 December 1998provides the ideal op
portunity to re-emphasize why WHO has strengthened its work on to
bacco control. There are six key reasons:
• Tobacco has a massive public health impact. The highly nega
tive impact of tobacco on health now and in the future is the primary
reason for giving explicit and strong support to tobacco control on a
worldwide basis. The increased use of tobacco is one of the greatest
public health threats for the 21st century.
r
• Over a billion people smoke - half of whom will die from their habit. Today there
are more than a billion smokers in the world, the largest share of them is in Asia. The propor
tion of women who smoke is higher in Europe and North America than in other parts of the
world. However, recent studies point to growing numbers of smokers in developing countries,
particularly among women.
• Tobacco use is bad economics. The economic impact of tobacco has been analysed in
many countries in recent years. These studies show that there are large direct, indirect and
intangible costs associated with tobacco that hamper economic development rather than
promote it.
• Tobacco harms the environment. In many of the tobacco-growing countries there is
evidence of the negative environmental impacts of tobacco agriculture, particularly when
associated with the deforestation required to extend farmland and fuel tobacco curing.
• Effective policies and interventions already exist. Effective policies and interventions
exist that can make a real difference to tobacco prevalence and consumption, and the associ
ated health outcomes. Most of the documented successes have occurred in developed coun
tries such as Canada where effective approaches have been implemented for years. More
recently, several developing countries and emerging economies have introduced similar meas
ures; early indications are that they too will be effective.
• Resources are inadequate relative to the size of the problem. Human, institutional
and financial resources for all aspects of tobacco control at country, regional and global levels
are severely inadequate. Faced with a USS 400 billion industry, global spending on tobacco
7
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I Framework Convention on Tobacco control
control has not addressed most countries' need for even a minimum level of human and
institutional capacity.
Canada, the host country for this meeting has stood alone for many years in supporting
international aspects of tobacco control. Over the past five years Health Canada has provided
more than a million Canadian dollars to WHO for its work on tobacco control; Canada's Interna
tional Development Research Council (IDRC) has spearheaded an initiative to strengthen inter
national tobacco control research; Canada supported a consultation on the framework conven
tion in Halifax, Nova Scotia, in June 1997; and recently the Canadian International Development
Agency (CIDA) provided its first funding for the new Tobacco Free Initiative. Canadian support
has not been restricted to the federal level or to funding. Canadian expertise in tobacco control
has and continues to play a vital leadership role in many organizations, including WHO, involved
in tobacco control. And the generous financial support of the Province of British Columbia for
the meeting has played a crucial role in building the momentum towards a framework conven
tion on tobacco control.
As the participants noted, the development of a proposed WHO framework convention on
tobacco control and possible related protocols will represent the first time that WHO has used its
constitutional mandate to facilitate the creation of an international convention. The framework
convention will be an international legal instrument that will circumscribe the global spread of
tobacco and tobacco products. With its possible related protocols, it will represent a global
complement to national and local action, and will support and accelerate the work of Member
States wishing to strengthen their tobacco control programmes.
When Member States come to consider a framework convention, they will need to be sen
sitive to sectoral issues, and to base their discussions on the factual evidence, keeping in view
the public health goals that are the principal reason for tobacco control. In this regard, the
Meeting of Public Health Experts focused on the public health issues which might be addressed
in the proposed WHO framework convention on tobacco control and possible related protocols.
At the same time, it examined international legal issues relating to the development of the
framework convention. As the report demonstrates, the meeting resulted in an effective bridg
ing of the public health and international legal perspectives.»
Dr Derek Yach
Project Manager
Tobacco Free Initiative
8
Remarks
by the Hon. Penny Priddy^
Minister of Health and
Minister Responsible for Seniors,
Government of British Columbia
n December 2,1998,1 had the privilege of welcoming the World Health
Organization to Vancouver, British Columbia, where they began talks
to forge an international treaty on tobacco control.
WHO is responsible for many great accomplishments. It wiped out
smallpox in this century. It is well on its way to eliminating polio. Now, the
world is looking to the WHO to inoculate the world's children against smok
ing. This will need a potent vaccine of legislation, regulation and education.
Director-General Dr Gro Harlem Brundtland, has said that tobacco is a communicated dis
ease — communicated by the advertising and promotion strategies of the multinational tobacco
companies.
Several Member countries have taken major steps to protect children against tobacco, by
banning advertisements and promotions. Other jurisdictions have developed their own mes
sages to counter industry advertisements. In British Columbia, we have taken the lead in Canada
in protecting our youth by combining increased public education, prevention and enforcement
activities, and legal action.
British Columbia is proud to be among the world's leaders in tobacco control. Ours is the
first jurisdiction in the world to demand full disclosure from the tobacco industry on the ingredi
ents in cigarettes — tobacco, paper and filters — and on the chemicals in both mainstream and
sidestream tobacco smoke. We have made that information available to the public in a web site
that is accessible around the world: www.cctc.ca.
In November 1998, the Government of British Columbia filed a lawsuit against tobacco
companies to recover health care costs paid to treat British Columbian smokers made ill by
tobacco.
9
Y
| Framework Convention on Tobacco control
British Columbia is the first Canadian province to take this kind of action against the to
bacco industry, but we hope it is just the beginning. As the United States has found, there is
strength in unity and we have indications that other provinces may take similar action.
Like many of WHO's Member States, we also have tough laws against selling cigarettes to
minors. We have an exciting prevention programme for youth. It ranges from school programmes
and contests to a public awareness campaign, which includes television advertising and posters
that speak to young people about the hidden dangers of tobacco.
The statistics on death and illness caused by smoking all have a human face. They are the
women whose precious years with their children and grandchildren are cut short. They are the
valued workers whose contributions to our society are diminished by illness and premature death.
They are the children who suffer chronic health problems resulting from exposure to tobacco
smoke.
Almost 6000 British Columbians and over 45 000 Canadians die prematurely each year of
diseases linked to smoking. Worldwide that toll is almost 4 million a year.
WHO estimates that, unless there are drastic changes in smoking habits, tobacco will be
come the leading preventable cause of death worldwide by the year 2030.
Our joint task is to concentrate on the future and prevent further casualties from tobacco.
But we face daunting challenges.
Tobacco is a problem that has no geographical boundaries. Just as corporate multinationals
market tobacco, so tobacco causes multinational social problems. The tobacco industry has a
record of challenging the rights of governments to legislate and opposing initiatives toward
tobacco control. The fact that WHO has taken on this challenge is a major step toward changing
the behaviour of the tobacco industry and letting the world know the truth about its products.
We are proud that WHO chose to hold this important meeting in Vancouver.
British Columbia has benefited from the assistance of other jurisdictions involved in tobacco
control and it is my hope that our experiences in British Columbia can serve as a model for
others.
We can best protect our children from the harm caused by tobacco by working together on
all aspects of control. >
10
|... I
IWS
J
Executive
r"^ri
.
I n recognition of the enormous premature mortality caused by tobacco, WHO, under the lead
I ership of its Director-General, Dr Gro Harlem Brundtland, has assigned priority to reinvigorated
I work on tobacco control, particularly in developing countries where the threatened toll of
tobacco use is greatest. A cornerstone of WHO's new Tobacco Free Initiative is the proposed
WHO framework convention on tobacco control (FCTC). The backgrounds of the meeting par
ticipants were primarily in public health, specifically in the area of tobacco control, and expertise
in international law/relations.
The dramatic rise and spread of the tobacco epidemic worldwide make the adoption and
implementation of the FCTC and related protocol agreements urgent. The FCTC will be an
international legal instrument designed to circumscribe the growth of the global tobacco pan
demic. Protecting and promoting global public health is its core objective.
The negotiation and implementation of the FCTC will make an enormous contribution to
global tobacco control efforts by promoting national and international awareness and mobiliz
ing technical and financial support for the promulgation of effective national tobacco control
measures worldwide. The convention will also serve as a platform for global cooperation on
aspects of tobacco control that transcend national boundaries. Cross-border substantive issues
that the FCTC or related protocols can address include: price and taxation; smuggling; duty-free
sales; advertising and sponsorship; Internet trade; package design and labelling; tobacco agri
culture; and information sharing.
The international regulatory strategy being used to promote global agreement and action
on tobacco control is the framework convention - protocol approach. This international regula
tory approach consists of two stages. States first adopt a framework convention that calls for
cooperation in achieving broadly stated goals, and establishes the basic system of governance to
address the issue area in question. Secondly, separate protocol agreements containing specific
measures designed to implement the broad goals called for by the framework convention can be
separately negotiated and adopted at the same time as the framework convention. The dynamic
and incremental convention - protocol approach has been employed successfully to encourage
international cooperation in a number of other international agreements, particularly in the area
of international environmental law.
The realization of the FCTC depends on engaging and expanding public participation, com
mitment and support. The negotiation and implementation of treaties is primarily the province
11
ng
| Framework Convention on Tobacco control
of governments. The FCTC will be developed by WHO's 191 Member States so that their con
cerns are adequately reflected throughout the process. The particular concerns of developing
countries must be addressed. Although many developing nations have capacity to address the
tobacco problem, the convention process must assist some countries in building sustainable
national capacity in tobacco control. For example, technical assistance in the development of
current data on the health, economic and environmental impact of tobacco, education and infor
mation, drafting and implementing legislation, and litigation should be provided where appro
priate. To support this technical assistance, provision for the establishment of a multilateral trust
fund, with contributions from governments, international agencies and private sources, should
be made in the convention.
In addition to Member States, other international organizations, nongovernmental organi
zations (NGOs) and other members of civil society can promote sustained commitment and
action for the FCTC. WHO can facilitate the support of NGOs in the convention process by
building information networks. ►
Note to the printer :
A photo has to be inserted here. It is on a seperated
file named Canadapl 2 (because this photo is in
colour)
12
Introduction
I n May 1996, in World Health Assembly resolution WHA49.17, Member States of WHO re
I quested the Organization to initiate the development of a binding international instrument
I on tobacco control. The specific form of legal instrument called for by the World Health
Assembly is a framework convention for tobacco control (the FCTC).
The subsequent creation of the Tobacco Free Initiative (TFI) at WHO refocused efforts and
resources on international tobacco control. The Vancouver meeting, which forms the subject
matter of this report, was the first technical consultation held in response to resolution WHA
49.17 since TFI was established. Public health experts from many countries gathered at the
meeting to discuss, amongst other things: how the FCTC could advance public health; WHO's
role in developing the convention; the issues from a developing country perspective; the role of
nongovernmental organizations; and options for the structure of the convention.
The Canadian Province of British Columbia graciously hosted and financed the Vancouver
meeting. The Minister of Health for British Columbia, the Hon. Penny Priddy, opened the meet
ing by reiterating the importance of tobacco control, the devastating impact tobacco has on
young lives, families and government treasuries, and the necessity for international efforts to
support actions being undertaken by national and subnational governments.
13
J__ |
Advancing the
Framework Convention
w
SESSION 1
TFI OVERVIEW AND THE FCTC ACCELERATED WORK PLAN
r ollowing of Dr Gro Harlem Brundtland's assumption of office as Director-General of the World
I Health Organization in July 1998, WHO reorganized its tobacco control efforts within a new
structure, the Tobacco Free Initiative (TFI). One of TFI's major projects is the advancement of an
international framework convention on tobacco control. The first two presentations at the meet
ing provided the necessary background information on WHO's tobacco control efforts.
The Tobacco Free Initiative
Dr Derek Yach, Project Manager of WHO's new Tobacco Free Initiative, described the long
term mission of global tobacco control as reducing the prevalence and consumption of tobacco
use in all countries and among all groups, and thereby reducing the burden of disease caused by
tobacco.
The goals of the Tobacco Free Initiative are to:
• Galvanise global political support for evidence-based tobacco control policies and actions;
• Build new, and strengthen existing, partnerships for action;
• Accelerate the implementation of national, regional and global strategies;
• Mobilize resources to support the required action.
Dr Yach emphasized that the problem was large and could only be effectively tackled through
international collective action. The solutions proposed would have net social benefits. This
applied particularly to the health and economic benefits: a tobacco-free world would be both
healthier and wealthier.
The content of the Convention would have to be sensitive to a wide range of development
needs of Member States. These should include meeting the transition costs of a few countries. The
costs arising under the convention should be equitably distributed according to both ability to pay
and the principle of "polluter pays". Thus it would not be equitable if countries that reaped the
benefit from tobacco trade did not contribute to the costs of foreign deaths, disease and misery.
15
Cover Story
SMOKE AND
DIE
0
V/ITP MB
Q
fa
a a
I
Government,
The Biggest Tobacco-Pusher
Dr S G Vaidya points out packs of deceits in tobacco lobby’s campaigns and says
anti-tobacco education campaigns are most unlikely to succeed. He calls for con
certed action, boycott of cigarettes, change in existing excise laws and taxation,
and the withdrawal of the Government of India from the tobacco industry.
"presently, the tobacco industry is in
power because of its marketing
- . strategies and strong support by the
government.
The powerful tobacco industry is hold
ing the government in its grip by spend
ing heavily on lobbying.
Presidents of the Indian Tobacco Asso£Layoil_.and^uccessive chairmen of pre
mier cigarette companies have thus been
able to mould policies to suit their inter
/hey have managed to convince the
government not to increase taxes on to
bacco products in line with inflation.
( igarettes thus remain one of the cheapes£prod_ucts.used by consumers.
Half-truth
Will anti-tobacco education ever suc
ceed?
From the twenty-five year experience
of Western countries which have launched
relentless anti-tobacco educational cam
paigns, the answer to this question is a
big ‘No.’
Professor David Sweanor, legal coun
sel to the Non-Smokers Rights Associa
tion of Canada, has said: “We need to be
reminded that during our twenty-five-yearfight against tobacco, world cigarette pro-
4
duction has doubled and per capita world
consumption has increased by twentyfive
How they pushed it
One of the first strategies adopted
by the Imperial Tobacco Company in
the 1920s was free sampling.
It was thus that the British pioneers
set about making Indians addicted to
cigarettes.
A district salesman was not con
sidered worth his salt if he did not give
away50,000 to 100,000 free samples
of cigarettes each monthl
How he did it was his business.
The pioneers used horse-drawn carts
plastered with placards, to go to the
villages and give away packets of
cigarettes to all and sundry.
Lucky dips, lantern processions,
riverboat cruises, elephants — these
people used every possible means to
popularise cigarettes.
In 1921, Scissors Wills was
launched with fabulous attractive
r'rizes.
Thus, over the course of more than
halfa century, millions ofpeople in In
dia, young and old, became tobacco
addicts and the Western 'life-style1 be
came a part of the Indian psyche.
per cent.”
Present-day advertisements reveal half
truths meant to deceive the consumer.
Cigarette companies use executives,
doctors, sports heroes, cine-actors and ac
tresses, politicians, army chiefs and even
national leaders (Winston Churchill and
Fidel Castro) to propagate a deceptive
image of smoking.
A doctor or an actor appearing in a ciga
rette advertisement conveys a positive im
age of smoking. Many young people, per
ceiving this as an enviable life-style, are
convinced into taking up smoking.
Government : biggest shareholders
While the government has accepted the
fact that smoking causes cancer, bronchi
tis, heart attacks, peptic ulcers — because
of the clout of the tobacco companies —
the industry continues to enjoy all sorts of
concessions in trade, import and export
and cash-credit.
In 1969, the entire government machin
ery — banks, financial institutions like
LIT,UTI,ICICI (Industrial Credit and In
vestment Corporation of India) — invested
in tobacco. Today, the government is the
biggest shareholder in cigarette compa
nies (35.54%) and hence a strong sup
porter of the tobacco trade.
Health Action • January
Subsequently, the government passed
the Tobacco Board Act (Act 4 of 1975),
which was later amended in 1985.
Accordingly, a Tobacco Board was es
tablished in December 1975 to look into
and regulate all aspects of the tobacco trade
— growing, grading, selling and buying
of tobacco; identifying new export markets,
maintaining and expanding existing ones;
sponsoring and assisting scientific, tech
nological and economic research for the
promotion of tobacco.
Under the trade liberalisation policy^
the government has allowed the tobacco
giant R.J Reynolds to establish a cigarette
factory in India.
It has also generously given a five-year
tax holiday to small units manufacturing
tobacco products in backward states.
This will release 5.5 billion cigarettes
on our youth.
It seems incongruous that the govern
ment seeks to enrich the backward states
by promoting a trade which is hazardous
to health.
A signature campaign to stall the fac
tory of R.J Reynolds, a U.S. cigarette gi
ant, has been started all over India. It aims
to petition the Prime Minister and Presi
dent to cancel the letter of intent issued to
the factory.
Hoodwinking villagers
According to Jagdish Kapoor, a di
rector of Parle Agro, tobacco com
panies use three elements of Rural
Marketing. They are:
9 The rural populace feels the
need to upgrade its standard of liv
ing and catch up with urban areas.
Smoking is looked upon and pro
jected as an urbanised, sophisticated
behaviour and a sign of being rich.
0 The rural consumer seeks to
ape a Western or urban life-style by
switching from beedi to plain ciga
rettes and then moving on to filter
cigarettes.
9 Brand association through
colours, visuals, numbers or tunes is
created and used to popularise the
brands. As literacy levels are low in
rural areas, brand association and
recall is not done by name, but by
colours like “Woh hare rang ka dena",
numbers like “Teen panch wallah”
(555) or pan “120 wallah.”
Health Action • January
yes, i oa
oo you
rruHc/ o me
smoktqj 2
In the face of such ‘committed’ gov
ernment participation in tobacco promo
tion, nationally and internationally, it is
naive to expect that the educational meth
ods that are being used by NGOs, occa
sional government press release to stop
smoking, rare newspaper articles and the
like, will have much of an effect.
How strong a fight can they put up
against the might of combined forces of
the tobacco giants?
Chances of reducing tobacco consump
tion appear bleak. In fact, a World Bank
Report has predicted a twelve percent in
crease of per capita consumption by 2000
AD for India.
It is, therefore, necessary that anti-to
bacco strategies have to be directed to
bring about a change in the existing ex
cise laws; taxation should be increased so
that smoking cigarettes is no longer a
cheap habit.
The laws and acts of Parliament which
have a promotional impact on tobacco
products need to be changed.
Individual resistance to smoking or
chewing has to grow into a mass resistance
— a boycott of cigarettes.
In our country, in the thirties, British
goods were boycotted. The cigarettes fac
tory at Saharanpur and three store-houses
of ITC had to be closed down for 2-3 years
as there was no demand.
Education about the health effects of
tobacco-use will sensitize the people*
But, concerted action has to be taken
by the elite, educated opinion leaders, poli
ticians and, in a democracy, by a mass
movement.
At the present moment, it is the tobacco
industry which is in power because of its
marketing strategies and strong support by
the government. We are thus at the mercy
of a government that wants us to “Run for
Fitness.”
We should instead run from the gov
ernment, who is after us to smoke
chew and thus contribute Rs.2500 crc
to the central exchequer, even at the ex
pense of ruining our health.
Only strong legislation; withdrawal of ;
the government from the tobacco indus-’
try and support given by it to the tobacco '
trade; sustained tax policy congruent with
health objectives, along with education,
will have some impact on tobacco con
sumption.
This is the only way by which we can
save our children and youth from un
wanted tobacco-linked disease and death.
(Third World Network Features).
(Dr S G Vaidya is the Honorary Secretary
of the Goa Cancer Society, a non-profit
organisation devoted to the prevention and
cure of cancer. He is also the chairperson of
the National Organisation for Tobacco Eradi
cation, or NOTE).
5
3-V
£ACT SHEET ON TOBACCO IN INDIA
Agriculture
Tn 1993,417,700 hectares were harvested and it is 0. 2% of all availableJnndL
7
Production and Trade
In 1992, 578,800 tonnes (7.0% of world unmanufactured tobacco) was produced in
India, making it the world’s third largert tpb^co Rowing country, In 1992, India
produce 767,436 million cigarettes and hides accounting for 13.5% of world total. About
2,100 million cigarettes were exported. Only 30 million cigarettes imported. In 1990,
India’s earnings from exports US$ 127.7 million compared with US$122.2 million in
1985:
Industry
In 1993 3.4 million engaged full time in manufacturing. This accounts for 11.7% V all
■ in
• growing
’
‘ . In 191’86,
manufacturing work About 0.9 million people work
and’ curing,
turnover of beedi industry was Rs. 4-5 crore pei (lay 25 lakhs beedi rollers in the
industry. 1^8 6,
UoU '
State cams substantial amount (3.5%) of its revenue from tobacco.
Tobacco consumption
7
c
Annual consumption declined between 1984 and 1992 from around 90 billion to about
8 5 Million. In 11992, 6.1% world unmanufactured tobacco and 1.5% of world total
manufactured cigarettes were consumed in India. 20% in the form of cigarettes and 40%
beedis and rest other forms. In 1990, tar levels in cigarettes from 18.0 - 28.0 mg and
nicotine 0.9 - 1.8 mg. Tai-level in beedis are higher at 45-50 mg. Ab cut*
'ntnco-o,
Prevalence:
LOk©
'bxdAC
0
i
Beedi smoking has risen during the last three decades. Cigarette smoking and other
forms declined considerably.
Tobacco use among population
65% of all men use tobacco (35% smoking, 22% smokes, 8% both). Overall among
women 3% but Bhavnagar 15%, Andhra Pradesh 67%.
India — 3,d largest tobacco manufacturer in the world . Nearly 50% oftobacco produced is
consumed in the domestic market annually (424 million kg consumed in the country and
94 million kg imported.
Smoking responsible for large number of fires in Industry and Agriculture. q 0
;'>- Ci
Op
Mortality: Tobacco is responsible significant amount of morbidity and mortality among
middle aged adults. India has one of the highest rates of oral cancer, Tobacco-related
cancers half of all cancers among men and one fourth among women. Oral cancer
accounts one third total cancer, with 90% of the patients having tobacco chewers.
Mortality: Every year 6,30,000 deaths tobacco related in India
(/ Over 60%* of heart pffients under 40 years of age on tobacco users; over half of the
patients aged 41-60 one also smokers.
Control on Tobacco products: Tobacco advertising banned in state control electronic
media but continues the private media In 1975 gqyemment has appintcd a full time
coordinator of tobacco control activities and at the some time initiated a Tobacco
Development Board for promoting tobacco by offering direct subsides and a price
support system to farmers.
Between 1987 and 1992 excise duty on cigarettes increased 64% to 112%. Cigarettes
taxes represent about 75% of retail price. Cigarette taxes on manufactured cigarettes and
low taxes on bidis and other tobacco products are encouraging substitution of bidies and
other products. In 9.7.1998, 1,100 crore earned through tobacco and Rs. 2400 crore
spent on patients suffering from tobacco related cancers.
Protection forjnon smokers: In 1990 government implements a prohibition or smoking all
government offices and educational institutions. Jn 1999 government prohibited in Trains
and Air ways.
Industry: 1998 B’C Limited got permission to treble its manufacturing capacity.
I
I
Minnesota's
Tobacco Settlement
Largest Recovery in Minnesota History
Under the settlement, the tobacco industry will pay the State more than S6.1 billion over
the next 25 years, making this the largest recovery in Minnesota history and the third largest in
American history. In its lawsuit, the State had sought damages of SI.3 billion for the cost of
treating smoking-related disease. The settlement is more than four and one-half times the
amount sought in damages. The Sute’s attorney’s fees will be paid directly by the tobacco
companies, on top of the State’s recovery.
The Truth Comes Out
A paramount goal of Minnesota’s litigation was to uncover the truth about the tobacco
industry’s forty-year conspiracy of lies. Through four years of bitter litigation, the State fought
its way into the industry’s secret documents. Now these hard-won documents will become
public, in what former Surgeon General C. Everett Koop has called one of the most significant
public health achievements of the second half of the Twentieth Century. Thirty-three million
pages of industry documents will be open to the public, along with the industry s computerized
“roadmaps” to the documents. The industry will pay to maintain a public document center in
Minnesota.
First-Ever Ban on Marketing to Kids
Under the settlement, the tobacco companies are specifically prohibited, by court order,
from using any marketing techniques that target children. We are unaware of any comparable
law or order anywhere. In the past, the only way to stop tobacco companies from targeting
children has been to argue that they are engaged in deceptive advertising or violation of other
general laws. Now, for the first time, they will be bound by a specific, ironclad order. And the
court will have the power to do whatever it takes to ensure compliance.
Cessation Options for Every Minnesota Smoker
The settlement provides for money to be set aside for a public^moking cessation fund, to
be supervised by public health experts. Under the settlement, more than $100 million will be
earmarked for this fund, which will offer a publicly-funded stop-smoking treatment opportunity
for every Minnesota smoker who wants to quit This fund is unprecedented.
The World’s Best Tobacco Control Program
Under the settlement plan, a non-profit foundation, run by a board of directors drawn mainlv
from prominent public health groups, will develop the world’s largest and most comprehensive
program to reduce teen smoking and combat the social and economic harm caused by tobacco. Subject
to the approval of the legislature, this foundation could receive a permanent endowment of more than
S650 million. An additional $100 million will be paid by the industry for research to get at the roots of
the tobacco epidemic. The interest on this endowment will fund a sustained counter-adverusing
campaign; classroom education; community partnerships; research; advocacy and innovative
prevention programs. This will be the world’s best-funded and, we hope, most effective campaign to
save future generations from becoming addicted to the world’s deadliest consumer product.
Tobacco Billboards Come Down
Cigarettes are the number one item advertised on billboards in Minnesota. But not for long.
Under the settlement, all tobacco billboards come down. Fifty come down within a month, and the
remainder will be phased out in less than six months. Tobacco advertising on buses, bus shelters and
taxis will also end.
No More Branded Merchandise
Tobacco companies spend almost $1 billion annually on T-shirts, hats, gym bags, backpacks,
CD players and other merchandise with cigarette logos, making our children “walking billboards” for
cigarettes. An amazing one-third of kids from 12 to 17 years old—including nonsmokers—own these
items. New research shows that this promotional merchandise may be one of the most powerful
influences in encouraging kids to smoke: children who own these items are four times more likely to
start smoking than those who don’t. More than 78 percent of Americans think this type of advertising
should be stopped. Now it will be. Under the settlement, this distribution of branded merchandise and
all branded promotional items, down to napkins and matchbooks, will be banned in Minnesota. This is
unprecedented.
No More Secret Payoffs to Movie Producers—Nationwide
Some critics have questioned whether state legal cases can help force nationwide changes in the
tobacco industry. This provision docs just that. One of the most insidious tobacco marketing
techniques has been the secret payment of fees to movie producers to feature cigarettes and smoking in
popular films, sometimes in ways that showcase particular brands. The industry claims it discontinued
this practice many years ago, but a document uncovered in the Minnesota case shows that Philip Morris
provided products for use in movies as recent, and as youth-oriented, as **The Muppet Movie” and
“Who Framed Roger Rabbit?” Speculation abounds about whether secret payoffs may have been made
to the makers of such recent, smoking-intensive movies as “Titanic” and “My Best Friend’s Wedding.”
Under this settlement, the companies are barred from making such payments, directly or indirectly. In
fact, it covers not only movies, but other entertainment media as well, from music videos to computer
games to live musical performances and television shows. Notably, this unprecedented provision
applies nationwide, demonstrating that state litigation can contribute significantly to national solutions
to the tobacco epidemic.
k
> i
Tobacco Trade Group Must Disband
In its lawsuit, the State had alleged that the tobacco industry used its so-called scientifc
research" aim. the “Council For Tobacco Research” (or CTR) as a tool in its conspiracy to
mislead Americans and suppress research and development of safer c.garettes The State alleged
that tins “research" effort prov.ded the industry with “cover" by mounting costly and endless
research tailored to avoid learning anything about the link between smoking and disease and
designed to perpetuate the myth that endless additional study was needed, bnder the settlement
this trade group - the industry’s so-called “scientific” arm, is dissolved and all its health research
forwarded to the FDA. The industry is permanently barred from reviving the CTR or anything
similar.
Expanded Lobbying Disclosure
The tobacco industry is notorious for manipulating the political process and wielding its
considerable clout through front-groups, highly paid lobbyists and secret surrogates^ The
segment imposes new disclosure requirements on the industry, beyond those of Minnesota s
fobbyTng and campaign finance laws, to shine the light of public scruUny on the industry s efforts
to influence Minnesota lawmaking. Among the enhanced disclosures will be reqinrement^; Uiat
±e industry reveal the amounts paid to its lobbyists and to other associations; reveal payments
made to third parties to testify in hearings, and so on; and report on the use of controlled
foundations to make gifts that benefit Minnesota officials. This is unprecedented.
Protecting the Integrity of the Legislative Process
The settlement contains provisions that help preserve Minnesota’s tobacco laws and that
limit the industry’s ability to block future legislation. The industry is specifically prohibited from
bringing any leTal challenge against Minnesota’s existing laws against selling tobacco to minors,
the Clean Indoor Air Act; the law against distribution of free tobacco samples, or the ne
ingredient disclosure law adopted in 1997 and not yet implemented. In addition, the industry
barred from opposing future legislation to reduce tobacco use by children.
Minnesota Benefits From Achievements in Future Cases
The settlement allows Minnesota to receive the benefit of any health gains, injunctive
language, or any other non-monetary terms that may be achieved in any future settlements e
industry negotiates with other states. This “most favored nauon” clause also guarantees
Minnesota’s right to take advantage of any attractive public health or reform terms m any
national tobacco legislation. In other words, no other state will receive more benefits than
Minnesota does.
AGJ26253 vl
Minnesota’s Landmark Tobacco Litigatixm
State of Minnesota By Humphrey and Blue Cross Blue Shield of Minnesota
vs.
Philip Morris, Inc., R^J. Reynolds Tobacco Company, Brown & Williamson Tobacco
Corporation, BAT Industries PLC, British-American Tobacco Company Ltd., BAT (UK &
EXPORT) Ltd., Lorillard Tobacco Company, The American Tobacco Company, Liggett
Group, Inc., The Council for Tobacco Research-USA, Inc. and the Tobacco Institute, Inc.
Ramsey County District Court
Court File No. Cl-94-8565
Selected Case Chronology: August, 1994-May, 1998
August 1994
Minnesota becomes the first state in the nation to sue tobacco companies for
consumer and antitrust law violations. Minnesota is also the first and only
state in the nation to sue in conjunction with a private, non-profit co-plaintiff.
Blue Cross Blue Shield of Minnesota.
November, 1994
The tobacco industry’s motion to remove or disqualify the law firm of Robins,
Kaplan, Miller & Ciresi from representing the State is denied. The District
Court cites the long history in Minnesota of Special Attorney Appointments.
Mav. 1995
The Court upholds the antitrust and special duty tort claims alleged by the
State and Blue Cross.
June, 1995
The Minnesota Document Depository is created in Minneapolis.
August, 1995
The Court adopts the Complex Litigation Automated pocket or CLAD system
for electronic filing of documents. Over 2,600 filings have been entered on
CLAD, including over 200 District Court orders.
March, 1996
The smallest tobacco company defendant, the Liggett Group, agrees to a
settlement with Mississippi, Maine, Florida, West Virginia and Louisiana.
Minnesota is the only litigating state to refuse settlement with Liggett
Attorney General Humphrey cites Liggett’s lack of full cooperation with the
states as the reason Minnesota refuses to join in the settlement
Mav. 1996
The United States Supreme Court rejects the industry’s efforts to obtain
review of orders requiring production of 4A document indices (roadmaps
created by the industry for its documents). This is the first of two
unsuccessful industry appeals to the United States Supreme Court.
1
V
I
July. 1996
The Minnesota Supreme Court rules Blue Cross has standing to join the Sur
of Minnesota in bringing consumer, antitrust and equitable claims acainst th
tobacco industry.
March, 1997
The Liggen Group agrees with the conditions Minnesota Anomey General
Humphrey demanded when Liggen’s initial settlement was rejected by
Minnesota and reaches a settlement with a larger group of Attorneys General
including Minnesou.
May. 1997
At the request of the State and Blue Cross, the District Court orders American
Tobacco and Broun & Williamson to produce documents and provide
complete answers on smoking and health research (CLAD 933).
May, 1997
The District Court finds the crime-fraud exception to the attorney-client
privilege applies to the tobacco industry’s claims of privilege. The Court
orders review of the documents by a Special Master (CLAD 943 & 944).
July. 1997
The Special Master conducts three days of hearings on the joint defense
claims made by the tobacco industry over approximately 2.400 Liggett
documents.
August 1997
The District Court unseals its May, 1997 crime-fraud Findings of Fact in
response to a motion by the media (CLAD 1275).
(
September. 1997
Tobacco manufacturers are required to produce lists which identify on a
brand-by-brand and year-by-year basis, the ingredients, chemical formulae
and processes for cigarettes sold in Minnesota. The Court orders Philip
Morris to produce information about documents in overseas research facilities
(CLAD 1300).
October, 1997
The Special Master conducts four days of hearings on the industry’s privilege
claims over thousands of documents.
November, 1997
The Court finds Philip Morris, RJ. Reynolds, Brown & Williamson, BAT
Industnes, British-American Tobacco Co., Lorillard Tobacco Co. and the
American Tobacco Co., along with five of the national law firms representing
V these companies, willfully disregarded an order to produce joint defense
agreements during the privilege hearings (CLAD 1720)
.
-
Decenibtn 1927
\ The District Court adopts the Special Master’s recommendation and orders
“that more than 800 Liggett documents be produced to the State and Blue
Cross. The Commerce Committee of the U.S. House of Representatives
subpoenas the Liggett documents from four of the tobacco companies and
posts the documents on the World Wide Web.
2
December. 1992
The District Court issues an order imposing sanctions on American Tobacco
and Brown & Williamson Tobacco for their willful disregard of the Court's
orders. The order requires an immediate payment of $100,000 to the Ramsey
County District Court and the production of 1,114 American Tobacco
documents pertaining to scientific research.
January. 1998
Trial commences in the federal courthouse in St. Paul.
February, 1998
The Special Master recommends disclosure of approximately 39,000
documents pertaining to scientific research, the addictiveness and
manipulation of nicotine, and public statements by the industry on tobacco
and health issues (CLAD 2224).
March, 1998
The District Court adopts the Special Master’s recommendations, ordering
release of the 39,000 documents to the State and Blue Cross. (CLAD 2345,
2348) The Court of Appeals and the Minnesota Supreme Court deny the
industry’s requests for further review.
March, 1998
The tobacco industry moves for a mistrial and recusal of Judge Fitzpatrick; the
motion is denied (CLAD 2398).
March, 1998
The Court imposes sanctions on BAT Industries and BATCo/BATUKE after
two BATCo scientific researchers, Alan Heard and Dr. Ray Thornton, fail to
appear for depositions as ordered. Sanctions include production of over 2,000
more secret industry documents (CLAD 2429).
March, 1998
The District Court orders public access to the Minnesota Depository (CLAD
2457). The State and Blue Cross maintain that still more information should
be public.
\pril, 1998
The United States Supreme Court denies the industry’s request for a stay of
the orders requiring production of 39,000 formerly “privileged” documents.
The Commerce Committee of the U.S. House of Representatives posts many
of the 39,000 documents on its website.
April, 1998
Chief District Judge Cohen denies the tobacco industry’s request for
rcconsideration/removal of Judge Fitzpatrick. Judge Cohen finds Judge
Fitzpatrick has been fair; that his rulings have been based on the evidence; and
- that there-is-no basis for a mistrial in the middle of thexase (CLAD 2555).
May, 1998
The District Court orders production of 458 additional “privileged” documents
on nicotine and addiction. (CLAD 2625).
May, 1998
Testimony concludes after 15 weeks of evidence, including thousands of
exhibits and 40 witnesses.
3
s
Minnesota's
Tobacco Settlement
At A Glance
Largest Monetary Recovery in Minnesota History
•
•
•
$6.6 billion (State plus Blue Cross) over 25 years: State’s payments in perpetuity thereafter
Four and one-half times the $1.7 billion sought
Tobacco companies pay the attorneys’ fees on top of State’s recovery
The Truth Comes Out
•
•
•
•
Over 33 million pages of secret industry documents opened to public
Document “roadmaps”—industry databases—become public
Industry funds Minnesota Document Depository for public use
Subject to court approval, more “privilege” documents become public
A Ban on Marketing to Kids
•
•
•
Permanently bans any marketing that targets children
First such order ever imposed anywhere
Enforceable with money penalties, injunctions and fines
Cessation Options for Every Minnesota Smoker •
•
•
$102 million fund
Subsidized stop-smoking opportunity for every Minnesota smoker who wants to quit
Unprecedented
The World’s Best Tobacco Control Program
•
•
•
Nonprofit health foundation to develop world’s best campaign to reduce tobacco use ■
Proposed permanent endowment of over $850 million, counting $102 million cessation fund
above
Interest on endowment funds counter-advertising, classroom education, community
partnerships, advocacy, research and evaluation in a comprehensive program to reduce
impact youth smoking
i
r
■'I
Tobacco Billboards Come Down
•
■
>
• All tobacco billboards eliminated within six months
• Transit ads (bus shelters, buses, taxis) eliminated
No More Branded Merchandise
•
•
•
Eliminates distribution of “gear”-hats, shirts, backpacks, etc.-with cigarene brands or logos
One-third of ail adolescents own cigarette gear
Kids who own this merchandise are four times more likely to smoke
No More Secret Payoffs to Movie Producers - Nationwide
•
Unprecedented nationwide ban on secret payments from tobacco industry to movie producers
to feature smoking in popular films
Tobacco Trade Group Must Disband
•
t
The tobacco industiy’s “scientific research” arm, the “Council For Tobacco Research” (or
CTR) permanently disbanded and dissolved
CTR can no longer function as industry “shield” to keep the smoking and health controversy ~
alive
y
Expanded Lobbying Disclosure
•
•
New lobbying disclosures for tobacco companies
Must reveal exact amounts paid to lobbyists and “front” groups: hidden payments for
legislative testimony; payments to third parties that eventually benefit politicians
Protecting the Integrity of the Legislative Process
•
•
Blocks industry legal attacks on youth smoking laws. Clean Indoor Air, other tobacco laws
Industry cannot oppose certain new laws to reduce youth tobacco use
• ?
. i:
Minnesota Will Benefit From Future Cases
• The settlement allows Minnesota to receive tfie' benefit of any htalth gains or other
non-monetary terms that are achieved in any future settlements with other stares
• In other words, no other state will receive more benefits than Minnesota does.
n
OCT.12.1998
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33
Health Law and Ethics
Prying Open the Door to the Tobacco
Industry’s Secrets About Nicotine
The Minnesota Tobacco Trial
Richard D. Hurt, MD; Channing R. Robertson. PhD
In 1994 the state of Minnesota filed suit against the tobacco
industry. This trial is now history, but its legacy will carry
on into the 21st century because of the revelations
contained in the millions of pages of previously secret in
ternal tobacco industry documents made public in the trial,
’n this article, we review representative documents relat
ing to nicotine addiction, low-tar, low-nicotine cigarettes,
and cigarette design and nicotine manipulation in cigarette
manufacture. These documents reveal that for decades,
the Industry knew and internally acknowledged that nico
tine is an addictive dnjg and cigarettes are the ultimate
nicotine delivery device; that nicotine addiction can be
perpetuated and even enhanced through cigarette design
alterations and manipulations; and that *health-consciousM
smokers could be captured by low-tar, low-nicotine prod
ucts, all the while ensuring the marketplace viability of their
products. Appreciation of tobacco industry strategies over
the past decades is essential to formulate an appropriate
legislative and public policy response. We propose key el
ements for such legislation and urge no legal or financial
immunity for the tobacco industry.
JAifA. 19S8580J178-1181
THE STAGE: THE MINNESOTA TOBACCO TRIAL
The medical community was allowed a glimpse inside the
tobacco industry with the 1995 publication of the Brown and
ViUiamson (B&W) tobacco papers,w Shortly before, in Au
gust 1994, the state of Minnesota filed suit against the tobacco
industry, ultimately leading to the relinquishment of million^
of pages of internal tobacco industry documents. The recent
release of previously protected attorney-client-privileged
documents, ordered to be produced on the basis of crime or
fraud, shed even more light on the industry’s secrets.
During preparation for testifying as expert witnesses for the
state of Minnesota, we reviewed thousands of pages of docu
ments dealing with addiction, low-tar, low-nicotine cigarettes,
and cigarette design and nicotine manipulation. We focus on
these areas in this article. The documents cited here were en-
tered as exhibits in the trial, and each one is representative of
hundreds of similar documents. That the documents come from
all major cigarette companies (hereafter referred to as the in
dustry) validates and extends the findings reported in the B &W
papers.1'® Although documents relating to cigarette marketing
to children7'10 and describing involvement of tobacco company
legal counsel in controlling certain aspects of company re
search1 144 were entered as evidence in the Minnesota trial, our
analysis focuses specifically on those documents addressing
nicotine addiction, delivery, and manipulation. (The names, po
sitions, and company affiliations ofthe individuals named in Uris
article are available from Dr Hurt,)
The documents we reviewed reveal little positive about the
tobacco industry or its supporters in advertising and public re
lations. They draw a dark cloud over the conduct ofthe attorneys
who have defended the industry over the years. It is critical for
the medical community to be'aware of the evidence introduced
in this trial about the actions and behavior of the tobacco industry so that it may help shape national policy toward the industry
aimed at protecting the public health. Full disclosure and full
accountability without consideration ofimmunity hasbeen called
for by organized medicine and public health leaders,1® and the
evidence from this trial unequivocally supports that position.
THE BEGINNING: CLOSING THE DOOR
TO THE TOBACCO INDUSTRY SECRETS
The stoty began on December 15,1958, when tobacco ex
ecutives and representatives of the public relations firm Hill
and Knowlton met secretly to develop an industiy response to
recently published data linking cigarettes to lung cancer.18,19
From this meeting emerged a strategy of creating doubt and
controversy over the scientific evidence, which was to be the
centerpiece ofthe industry’s defense for decades to come. The
industry position was made public on January4,1954, with the
publication of "A Frank Statement to Cigarette Smokers.’®5'21
Working drafts of the statement reveal that just before pub
lication, substantial changes were made, including the elimi
nation of the sentence, ‘We will never produce and market a
product shown to be the cause of any serious human ailment.'’16
From the Nicotine Oepend0r*»ce Center. Mayo Clinic and Mayo Foundation, Roch
ester, Minn (Dr Hurt), and the School Engineering. Department of Chemical Engi
neering, Stanford UnMrarty, Stanford. Caff! (Dr Robertson).
Reprints; Richard D. Hurt, MD, Nicotine Dependence Center. Mayo Clinic. 200 First
St SW, Rochester, MN 55905.
JAMA. October 7.199&-Vol 280, No. 13
• n •’’.A’• i’n?."’•
A*..”.
.
\ ‘.M-r n
Health Law and Ethics section edllory Laurence O. Gostin, JD. the Georgetown/
Johns Hopkins UnK/er»fy Program on law and Public Health. Washington, DC, and
Baftrmora, Md; Helene M. Cola. MD. Contributing Editor, OAMA
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Importantly, the final version of the statement made the fol- ■ ■
lowing pledge; “We accept an interest in people’s health as a
baric responsibility, paramount to every other consideration
in our business,”21’ a pledge the industry failed to keep. ■
Efforts to gain the public trust amidst in-house acknowl
edgment ofthe deceit were widely evident in these early years. ■
Documents detailing planning that occurred in the early
months of 1954 contained the following statements:
There is only one problem—confid ence, and how to establish it; public
assurance, and how to create it—in a perhaps long interim when sci
entific doubts must remain. And, most important, how to free millionB
of Americans from the guilty fear that is going to arise deep in thenbiological depths ... evepr time they light a cigarette.... The very
first problem is to establish some public‘confidence in the industry’s
leaders themselves, so that the public will believe their assertions of
their own interest in the public health;... to reassure the public and
still instinctive fears ... if any cancer-causing agent is ever really
found in tobacco, the manufacturers will quickly find a way to elimi
nate it.”
Review of internal company documents from the 1850s re
vealed industry acknowledgment of the scientific evidence of
nicotine’E addictive properties and linking illness with ciga
rette smoking. Research directors interviewed in early 1954
-'mmented, "It’s fortunate for us that cigarettes are a habit
.Ley can’t break,” and "Boy, wouldn’t it be wonderful if our
company was the first to produce a cancer-free cigarette.
What we could do to the competition!”16 Interviews conducted
in 1958 by British American Tobacco (BAT) scientists at 18
institutions and research laboratories in North America, in
cluding 8 tobacco companies, the Scientific Advisory Board of
the Tobacco Industry Research Committee, the National Can
cer Institute, and several academic institutions, found only 1
dissenting voice to the question of whether a causal relation
ship between cigarette smoking and lung cancer had been es
tablished.22
NICOTINE AND ADDICTION
Industry Understanding
Nicotine’s addictive properties were acknowledged inter
nally by 1968/ but a reason for continued public denial was
made clear in a 1980 Tobacco Institute document from Mr P. C.
Knopick to Mr W. Kloepfer, senior vice president for public
relations’.
ook, Hardy [Shook, Hardy, and Bacon, LLP, is a Kansas City, Mo,
law firm that has directed legal strategy for the tobacco industry1 A<]
reminds us, Pm told, that the entire matter of addiction is the most
potent weapon a prosecuting attorney can have in a lung cancer/
cigarette case. We can't defend continued smoking as "free choice” if
the person was "addicted.”3
Other documents revealed a long-standing recognition of
the pharmacological effects of smoking and nicotine, including
both addiction and tolerance. Sir Charles Ellis, a scientific ad
viser to BAT, in a 1962 document stated, "What we need to
know above all things is what constitutes the hold of smoking,
that is, to understand addiction.”14 He went on to say:
Aa a result of these various researches, we now po&sees a knowledge
of the effects of nicotine far more extensive than exists in published
scientific literature.... We believe that we ha-ve found possible rea
sons for addiction in tw0 other phenomena that accompany steady ab
sorption of nicotine. Experiments have so far only been carried out
■with rate, but with these it is found that certain rats become tolerant
to repeated doses and after a while show the usual nicotine reactions
but only on a very diminished scale.... Supposing the tranquilizing
1174 JAMA. October 7.1998—Vol 280, No. 13
P.3
action ofnicotine can be tracked down in this way, then these reactions
wiU be compared in the case of rats who have never had nicotine, or al
ternatively have become addicted to it. Subsequent rimilar measure
ments V’ill be made on human nonsmokers and on addicted smokers.3
The addictive potential of a drug is enhanced by delivery
systems that cause it to reach the brain more quickly,25 a con
cept fully appreciated by industry scientists. A1964 document
from H. D. Anderson, vice president of research and develop
ment (R&D), to R, P. Dobson, president of BAT, discussed
adding potassium carbonate to tobacco: "There seems no
doubt that the Trick’ of a cigarette is due to the concentration
of nicotine in tlie bloodstream which it achieves, and this is a
product of the quantity of nicotine in the smoke and the speed
of transfer of that nicotine from the smoke to the blood
stream.”®
Sustaining the Health Conscious Market
As public concern about the health effects of smoking in
creased, the industry developed strategies to confront that con
cern. In a 1972 Tobacco Institute document, Fred Panzer, vice
president, in a report to Horace R. Kornegay, president, re
viewed the industry’s strategy to "defend itself on three major
fronts—litigation, politics, and public opinion.”27 That strategy
included "creating doubt about the health charge without ac
tually denying it” He went on to say, ‘Tn the cigarette contro
versy, the public—especially those who are present and poten
tial supporters (e.g. tobacco state congressmen and heavy smok
ers)—must perceive, understand, and believe in evidence to
sustain their opinions that smoking may not be the causal fac
tor,’®7 A possible new strategy was proposed: ’Thus there are
millions of people who would be receptive to a new message,
stating. Cigarette smoking may not be the health hazard that
the anti-smoking people say it is because other alternatives are
at least as probable.”27 In this way,- the industry sought to create
doubt about the health consequences ofsmoking, allowing smok
ers to rationalize their continued use.
The industry also understood that reassuring the smoker
that low-tar’ and low-nicotine delivery cigarettes were safe
supported continued smoking. A December 1976 Lorillard
document stated:
Health concerns are the usual reasons for switching to alow T&N [tar
and nicotine) brand. Such cigarettes are "better for you”—milder and
less irritating (now) as well as less likely to cause serious problems
Cater).... To many SHF [super-high-filtration] smokers, a low T&N
cigarette represents a compromise smoke between a more satisfying
smoke and not smoking at all.... Most "health oriented” smokers ex
hibit an openness to changing their cigarette brand on safety as well
as other grounds. To deal with this ambivalence, they rationalize (e.g.,
"I may be better off smoking'7), they compromise (turning to “milder’'
or lower tar and nicotine cigarettes; trying to smoke less), and they
temporize ("I’ll quit when things quiet down around here”).®
The report concluded by saying, "This research indicates a
number of directions for approaching the ‘health-oriented’
cigarette market with viable new, improved and optimized
product/marketing concepts” and outlines a way of "Targeting
to Health-Oriented Market Segments.”13
Characteristics of Addiction
Denial, rationalization, and reinforcement are key elements
in the addictive process, concepts that the industry under
stood very well. The importance of nicotine in the addictive
process was expressed in a variety of ways. In a 1969 Philip
Morris memo, W. L. Dunn (known within the industry as "The
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Nicotine Kid”) discussed reinforcement: “Perhaps this is the
key phrase: the reinforcing mechanism of cigarette smoking.
If we understand it, we are potentially more able to upgrade
our product”® In a 1978 Philip Morris memo from senior sci
entist T. S. Osdene summarizing a Council for Tobacco Re
search meeting, he stated, 'Tin Seligman [Philip Morris re
search director] brought up the grant by Dr. Abood in which
one of the stated aims was to make a clinically acceptable
antagonist to nicotine. This goal would have the potential of
putting the tobacco manufacturers out ofbusiness.”30 In a 1978
B&W memo from H. D. Steele to M. J. McCue, Steele stated,
“Very few consumers are aware of the effects of nicotine, Le.,
its addictive nature and that nicotine is a poison."31 Others
were more blunt, such as a 1983 B&W memo that stated, "Nico
tine is the addicting agent in cigarettes."32
Further understanding of the addictive process is shown in
a 1979 BAT document summarizing a survey of 2018 smok
ers.® It stated:
Rationalization through modifying smoking behatior is a feasible
means of conflict reduction.... One way of reducing the conflict
within the smoker is to deny, devalue or otherwise rationalize the
.health argument The four modes of potential conflict reduction dis
cussed bo far rely on either a fatalistic disposition to health or a faith
in “safer’' smokingi or a denial of anti-smoking information.31
This health reassurance strategy was pervasive among the
companies. In a 1973 speech, Dr A. W. Spears, then a re
searcher and now the chief executive officer at Lorillard, Baid:
Bafore concluding my remarks on product acceptance, I want to return
to the element ofpsychologic acceptance and discuss another component
of this element which I wfll call “Health Psychology.'’ Clearly the
consumer is concerned about smoking- and health and is convinced in
varying degrees that smoking is a possible deterrent to his health. Pres
ently, this factor is of active interest to R&D since it has been used to an
advantage in marketing both the Kent and True brands.14
Nicotine the Addicting Drug
and the Threshold Dose of Nicotine
For cigarettes, as with all drug delivery devices, it is critical
to ensure that the drug (ie, nicotine for cigarettes) is delivered
to the recipient within a dose range window, the upper bound
dictated by toxic effects and the lower bound defined by the mini
mal dose required to achieve the desired pharmacological ef
fect, Recent proposals from the scientific community have called
for consideration ofreducing the absolute level ofnicotine in ciga
rettes to a point where adolescents would not be able to become
dependent45 The industry also focused on this ‘threshold dose”
but from the opposite and much darker perspective, ie, not to
avert addiction but to maintain it A1980 Lorillard document sum
marized the goals of an internal task force, one of which was to
“[determine the minimum level of nicotine that will allow con
tinued smoking. We hypothesize that below some very low nico
tine level, diminished physiological satisfaction cannot be com
pensated for by psychological satisfaction. At this point, smokers
will quit or return to higher T&N brands.,afl Another example
of this thinking is a 1971R. J. Reynolds (RJR) document that
listed as an item for future research “Habituating level of nico
tine (how low can we go?).”” A1982 BAT memo noted:
Ifdelivery levels are reduced too quickly or eventually to a level which
is so low that the nicotine is below the threshold of pharmacological
activity then it is possible that the smoking habit would be rejected by
a large number ofsmokers.... The simple answer would seem to be to
offer the smoker a product with comparatively high nicotine delfver-
P.4
ies so that with a minimum of effort he could take the dose of nicotine
suitable to his immediate needs.*
Similar sentiments had been expressed in 1978 by Creigh
ton at BAT who added, “It is not known where this threshold
between just acceptable and rejection lies.”” In 1976 S. J.
Green, a scientist and research director at BAT, stated, .“Nico
tine is an important aspect of ‘satisfaction’, and if the nicotine
delivery is reduced below a threshold ‘satisfaction’ level, then
surely smokers will question more readily why they are in
dulging in an expensive habit/’" Similar research was under
way at RJR in 1977, where researchers were conducting an
extended-use consumer study to provide a more definitive
idea of "optimum and minimum nicotine levels?*41 A 1980
Philip Morris memo from W. L. Dunn to R. B. Seligman, vice
president for R&D, about cigarettes with high ratios of nico
tine to tar stated, “If even only some smokers smoke for the
nicotine effect (I personally believe most regular smokers do),
then in today’s climate we would do well to have a low TPM
[total particulate matter] and CO [carbon monoxide] deliver
ing cigarette that can supply adequate nicotine.’’42
For decades, industry scientists, executives, and lawyers
have known full well that nicotine is addicting and that they
are in the business of developing, manufacturing, and selling a
drug delivery device—thecigarette. Clearly, the industry was
concerned with identifying the minimum dose threshold for
nicotine that the device could deliver. This is further exempli
fied by brands designed to explore the lower reaches of nico
tine delivery levels, ie, Merit-DeNic, Benson and Hedges
DeNic, and N ext, the failure of which was prophesied by W. L.
Dunn in 1972: *No one has ever become a cigarette smoker by
smoking cigarettes without nicotine,”43
CIGARETTES; THE HOLY GRAIL
OF DRUG DELIVERY DEVICES
Tobacco or Drug Industry?
The cigarette is a sophisticated nicotine delivery device al
lowing nicotine to be manipulated both physically in terms of
amount and chemically in terms of form to ensure a pharma
cologically active dose can be obtained bythe smoker. That the
smoker can control the nicotine dose by altering smoking be
havior makes the cigarette one of the most technologically so
phisticated drug delivery devices available.
That nicotine is a drug, that the cigarette is a delivery
device, and that tobacco companies are in the drug business
have not escaped the industry. Claude E. Teague, Jr, assistant
director of research at RJR, could have been speaking for the
entire industry in a 1972 memorandum;
In a sense, the tobacco industry may be thought of as being a special
ized, highly ritualized and stylized segment of the pharmaceutical in
dustry. Tobacco products, uniquely, contain and deliver nicotine, a
potent drug with a variety of physiological effects.... Thus a tobacco
product is, in essence, a vehicle for delivery of nicotine, designed to
deliver the nicotine in a generally acceptable and attractive form. Our
Industry is then based upon design, manufacture and sale ofattractive
dosage forms of nicotine, and our Company's position in our Industry
is determined by our ability to produce dosage forms ofnicotine which
have more overall value, tangible or intangible, to the consumer than
those of Our competitors. Ifnicotine is the sine qua non of tobacco
products and tobacco products are recognized as being attractive
dosage forms ofnicotine, then it is logical to design our products—and
where possible, our advertising—around nicotine delivery rather
than “tar” delivery or flavor.... If, as proposed above, nicotine is the
sine qua non of smoking, and ifwe meekly accept the allegations ofour
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critics and move toward reduction or elimination of nicotine from our
products, then we shall eventually liquidate our business. Ifwe intend
to remain in business and our business is the manufacture and sale of
dosage forms of nicotine, then at some point we must make a stand."
Summarizing future courses of action for the industry, Teague
made 8 key points about nicotine, including the need to "more
precisely define the minimum amount of nicotine required for
‘satisfaction’ in terms of dose levels, dose frequency, dosage form
and the like” to be investigated through biological and other ex
periments; and the need to “[s]tudy means for enhancing nico
tine satisfaction via synergists, alteration of pH, or other means
to mirrimiz-e dose level and maximize desired effects?1*4
Publicly admitting that nicotine is a drug had potential
regulatory implications. In a 1969 Philip Morris document,
Dunn wrote to H. Wakeham, director of R&D, “I would be
more cautious in using the pharmic-medical model—do we re
ally want to tout cigarette smoke as a drug? It is, of course, but
there are dangerous FDA implications to having such concep
tualization go beyond these wallB.”® Dunn expressed similar
concerns in a 1980 letter to R. B. Seligman concerning nicotine
receptor programs: "Any action on our part, such as research
on the psychopharmacology of nicotine, which implicitly or
-’xplidtly treats nicotine as a drug, could well be viewed as a
.icit acknowledgment that nicotine is a drug. Such acknowl
edgment, contend our attorneys, would be untimely,”12 He
went on to say, “Our attorneys, however, will likely continue
to insist upon a clandestine effort in order to keep nicotine the
drug in low profile.”12 A, D« McCormick at BAT in 1974 was
also concerned about the FDA: “If tobacco were to be placed
under a Food and Drug law, classification oftobacco under the
food section would be acceptable, but classification of tobacco
as a drug should be avoided at all costs.”45 In a 1972 RJR memo,
Claude Teague (senior researcher at RJR) wrote; "What we
should really make and sell would be the proper dosage form
of nicotine with as many other built-in attractions and gratifi
cations as possible—that is, an efficient nicotine delivery sys
tem with satisfactory flavor, mildness, convenience, cost,
etc.”44 In a 1980 memo to R. B. Seligman and directors ofPhilip
Morris, Osdene outlined the priorities for “Evaluation of Ma
jor R&D Programs,”4® a memo that also shows the level of
communication by the scientists to top management. About
the nicotine program, he stated, “This program includes both
behavioral effects as well as chemical investigation. My reason
ir this high priority is that I believe the thing we sell most is
mcotine And, in a 1983 brainstorming session at RJR, D, L,
Roberts wrote: “A short definition is that a cigarette supplies
nicotine to the consumer in a palatable and convenient form.’*17
The concept of the cigarette as a drug delivery device is
deeply rooted in the industry. W. L, Dunn, in a 1972 Philip
Morris document, summarized the discussion at a conference
attended by 25 scientists from England, Canada, and the
United States:
The majority of conferees would atcept the proposition that nicotine
is the active constituent of cigarette emoke-.., The cigarette should
be conceived not as a product but as a package. The product is nicotine.
Think ofthe cigarette pack as a storage container for a day’s supply of
nicotine.... Think of the cigarette as a dispenser for a dose unit of
nicotine.... Think of a puff of amoke as the vehicle of nico
tine. ... Smoke is beyond question the most optimized vehicle ofnico
tine and the cigarette the most optimized dispenser of smoke.41
B. Reqter, from the marketing divirion of Philip Morris (and
R, R. Johnson, a brand manager and senior scientist at B&W,
1176 JAMA, October 7,1698—Vo( 280. No. 13
P.5
voiced similar opinions. Reuter said, “Different people smoke
for different reasons. But, the primary reason is to deliver
nicotine into their bodies,Johnson’s opinion was that “we
are in a nicotine rather than a tobacco industry,”" With a com
parable mindset, researchers at BAT wrote, “BAT should
learn to look at itself as a drug company rather than as a
tobacco company.”*1’
Indeed, each of the major cigarette companies has designed,
manufactured, and in some cases test-marketed nicotine de
livery devices that have the look and feel of cigarettes but are
engineered for the sole purpose of delivering nicotine in con
trolled dosage forms: “Philip Morris has chosen to pursue a
nicotine delivery device that, like BJR’s Premier [previously
marketed as a smokeless ‘cigarette’], continues the cigarette
tradition of sucking on a cylindrical mouthpiece to inhale .
flavorings and nicotine from a tobacco based product,”43 Im
portantly, what sets cigarettes apart from other drug delivery
devices is that any “therapeutic” effect is outweighed by the
adverse consequences of the delivery system.
Manipulating Nicotine Delivery
The industry pursued multiple avenues to manipulate nico
tine to achieve desired delivery concentrations, In a 1963
memo from R. B. Griffith of B&W to J, Krwan at BAT,
Griffith wrote:
Nicotine is by far the most characteristic single constituent in tobacco,
and the known physiological effects are positively correlated with
smoker response.... I think that we can say even now that we can
regulate, fairly precisely, the nicotine and sugar levels to almost any
desired level management might require. Of this I am confident.51
A1984 BAT R&D memo stated:
Irrespective ofthe ethics involved, we should develop alternative de
signs (that do not invite obvious criticism) which will allow the smoker
to obtain significant enhanced deliveries should he go wish..., An
other area of importance is the exploitation ofphysical and chemical
means to increase nicotine transfer, i.e. to increase the effective utili
zation of nicotine.®
Apparent changes in crop processing in the early 1980s
caused the industry eome concerns. H. E. Guess® ofRJR wrote
that trends in lower levels of nicotine in flue-cured crops would
produce “less satisfying*’ cigarettes, and he suggested a “nico
tine control system with upper and lower limits” to address this
problem. Summaries from a 1984 BAT conference on smoking
behavior noted the need to “improve our ability to ‘control’ the
level of nicotine in smoke,”54 and a 1982 report from Lorillard
documents a significant long-term effort to investigate adding
nicotine to cigarettes from exogenous sources.®
As expected, the cigarette industry was and is highly skilled
in the physical and chemical means to manipulate nicotine.
These range from tobacco blend modifications, alterations in
cigarette dimension, filtration, ventilation, paper porosity,
additives, and the ratio of tobacco shred size to tobacco weight
per cigarette. ‘Tuffing” (a process of expanding reconstituted
tobacco to increase its volume) of tobacco for cigarettes was
once accomplished by adding Freon to the reconstituted to
bacco.® (Burning Freon produces the toxic gas phosgene.) In
an effort to make blend adjustments, RJR entered into a joint
research agreement with a biotechnology company to geneti
cally engineer tobacco plants to manipulate nicotine levels.57
With simUar goals, B &W developed and has used a genetically
engineered tobacco called Yl, which has "increased nicotine
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content versus traditional tobaccos” while containing the
same tar level.68
THE SCAM: LOW-TAR, LOW-NICOT1NE CIGARETTES
Feeding the Smoker’s Addiction
In further exploitation of smokers’ rationalisation and de
nial defenses, the industry developed and promoted low-tar,
low-nicotine cigarettes with an implied reduction in health
consequences. Benowitz et al® published the first widely rec
ognized article in a medical journal about smoker compensa
tion when smoking low-tar, low-nicotine cigarettes. Com
menting on this article in an internal memo, J. H. Robinson,
an RJR researcher, wrote:
The paper itself expresses what we in Biobehavioral have "felt” for
quite some time. That is, smokers smoke differently than the FTC
[Federal Trade Commission] machine and may very well smoke to
obtain a certain level of nicotine in their bloodstream. If a given level
of nicotine in the blood is the final goal of a smoker, one would predict
that he would smoke an FFT [full flavor tar] and ULT [ultra low tar]
cigarette differently.... This all falls under the area of smoker com
pensation which we have been interested in studying for some time
now.®
Citing an earlier investigation of smoking compensation
comparing the German Camel cigarette and Marlboro, Robinjon wrote, “The smokers apparently obtained'almost exactly
the same amount of nicotine no matter which of the fofir ciga
rettes they smoked This was one of the first indications that
smokers may in fact smoke to obtain a certain level of nicotine
in the bloodstream."® Despite his apparent recognition of
smoking behavior with the goal of obtaining a given level of
nicotine in the bloodstream, consistent with behaviors associ
ated with other drugs of addiction, Robinson®1 has been a vo
ciferous opponent to classifying nicotine as an addicting drug.
Making and Marketing Health Reassurance Cigarettes
In response to health concerns surrounding cigarettes, the
industry began to produce products that were meant to reas
sure the health-conscious consumer, A Philip Morris review of
the 1964 surgeon general’s report stated:
The onus ofproofhas been moved by the report from its usual position
with the industry’s accusers to the tobacco industry itself,... An un
fortunate impression at the committee's press conference that “filters
do no good** was at least substantially rectified by Senator [John
Sherman] Cooper [of Kentucky].®
One of the recommendations for company research policy
was to “provide a substantive basis for vigorous health adver
tising by publication of suitable articles in the technical litera
ture."®2 In a section entitled industry Posture Vis-a-Vis
Public," the review stated, “The health value of filters is
undersold in the report and is the industry’s best extant
answer to its problem. The Tobacco Institute obviously should
foster the communication of the filter message by all effective
means."®2 Further on the review stated that “the industry
must come forward with evidence to show that its products,
present and prospective, are not harmful?'* Unfortunately for
the consumer, the issue of harm was never addressed, and in
stead, the industry promoted their products as providing a
modicum of health reassurance” but not reductions in harm.
R. Short, a marketing manager for BAT, wrote:
It was abundantly dear, for example, a£ a result of our recent visit to
the U.S.A, that manufacturers are concentrating on the low TPM [toJAMA, October 7, 1098—Vol 200, NO. 13
P.6
tai particulate matter] and nicotine segment in order to create brands
with distinctive product features which aim, in one way or another, to
reassure the consumer that these brands are relatively more
"healthy" than orthodox blended cigarettes like VICEROY MARL
BORO and WINSTON.®
A December 1976 Lorillard document outlined the impres
sion most people had (and still have) about low-tar, lownicotine cigarettes!
People believe that cigarettes low in tax and nicotine have different
“tobacco" ingredients and different kinds of filters than other
cigarettes—the tobacco is milder or a special mild blend, perhaps
treated to remove tar and nicotine, perhaps mixed with additives or
fillers, perhaps cured differently—or maybe just more loosely
packed.... Those who smoke low tar and nicotine cigarettes gener
ally do so because they believe such cigarettes are “better for you.”88
Smoker Compensation
Industry scientists were well aware that smokers compen
sated when smoking low-tar, low-nicotine products. A 1978
BAT document by D. E. Creighton went into great detail about
compensation: “No smoker has yet been observed who smokes
with the same pattern as a smoking machine,"*9 He defined
compensation to mean “subconscious changes made to the
smoking pattern by a smoker in an attempt, which may or may
not be successful, to equalize the deliveries of products which
have different deliveries when smoked by machine under stan
dard conditions?*18 Creighton stated that many experiments
have been carried out in Hamburg, Germany, Montreal, Que
bec, and Southampton, England, within the company as well as
other experiments by research workers in independent orga
nizations to confirm that compensation occurred, He went on
to say.
[T]here is now sufficient evidence to challenge the advice to change to
a lower delivery brand, at least in the ehort-term. In general, a major
ity of habitual smokers compensate for changed delivery, if they
change to a lower delivery brand than their usual brand. Ifthey choose
a lower delivery brand which has a higher tar to nicotine ratio than
their usual brand (which is often the case with Iowet delivery prod
ucts), the smokers will in fact increase the amounts of tar and gas
phase that they take in, in order to take the same amount of nicotine.
More realistic adyice to smokers would be to choose a brand with a
lower tar to nicotine ratio which gives them the satisfaction that they
require in the lowest amount of smoke taken in.”
An early 1970a paper by Colin Greig, in R&D for BAT, ad
dressed compensation with some personal observations of his
mother-in-law, whom he surreptitiously provided with lowtar cigarettes.*4 He watched her smoke them more intensely,
apparently to compensate for lower delivery. He wrote:
I suggest that there is a parallel with cigarettes—we may smoke a low
delivery cigarette—but in times of tension or altered mood we want a
stronger one. What happens? Either we smoke one more intensely
(remember, there is no single dose for a cigarette)—■or we smoke two
in rapid succession. A dilemma appears—do we design a compensat
able cigarette—<and sell one—or the non (or minimally) compensat
able cigarette—to sell two? Given the Unit cost, it is very probable that
the second option is not viable—so we have, perhaps, to do the first."
A 1975 Philip Morris memo about compensation stated:
The smoker profile data reported earlier indicated that Marlboro
Lights cigarettes were not smoked like regular Mariboros. There were
differences in the size and frequency of the puffs, with larger volumes
taken on Marlboro Lights by both tegular Marlboro smokers and Marl
boro Lights smokers. In effect, the Marlboro 85 smokers in this study
did not achieve any reduction in the smoke intake by smoking a
cigarette (Marlboro Lights) normally considered lower in delivery,®
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The mechanics of compensation, ie, smoking with greater
intensity, deeper inhalation, and larger puff volumes, was the
topic of many documents.32^®’67
In a 1981 BAT document by M. Oldman, major points that
were discussed -included:
The nature of possible compensation phenomena in relation to highly
ventilated cigarettes was discussed at length. It was noted that we
have very little data on the long-term consequences of smoking
behavior patterns following switching to low tar products.... It was
agreed that efforts should not be spent on designing a cigarette which,
through its construction, denied the smoker the opportunity to com
pensate or oversmoke to any Significant degree “
Surveys conducted as recently as 1996 indicate that more
than two thirds of American smokers are unaware that there
are ventilation holes in cigarettes.^-71 Even regular, full-flavor
cigarettes such as Winston “Reds” have had ventilation holes
in the filters since the early 1980s.72 Industry scientists knew
the full implications of this technology as evidenced in a 1987
BAT document that reported the effects of blocking ventila
tion holes on tar and nicotine delivery; the more holes that are
blocked, the higher the delivery becomes,n
.
Honesty or Cheating?
That creating doubt about the health risks of smoking was
primary goal of the industry is evidenced in a BAT Senior
Marketing Conference summary report from 1977.’7 The out
come of the conference summarized the new approach to mar
keting; "All work in this area should be directed towards pro
viding consumer reassurance about cigarettes and the smok
ing habit This can be provided in different ways, e.g. by
claimed low deliveries, by the perception oflow deliveries and
by the perception of ‘mildness? ’wa
Later that year, at a meeting of the BAT Chairman’E Ad
visory Committee III, several questions were raised regard
ing low-tar, low-nicqtine delivery cigarettes:
Should we market dgaretteB intended to reassure the smoker that
they are Safer without assuring ourselves that indeed they are bo or
are not less safe? For example, should ^e "cheat’’ smokers by “cheat
ing" League Tables? [League tables are the British equivalent of the
FTC ratings of cigarette delivery of tar and nicotine.] If we are
prepared to accept that government has created league tables to en
courage low delivery cigarette smoking and further if we make league
tables claims as implied health claims—or allow health claims to be so
implied—should we use our superior knowledge of our products to
design them so that they give low league table positions but higher
'’veries on human smoking? Are smokers entitled to expect that
irettes shown as lower delivery in league tables will in fact deliver
less to their lungs than cigarettes shown higher?’4
The response of the industry to these and similar questions
is dear; the industry chose to continue to deceive their cus
tomers.
OPTIMIZING THE EFFECT; FREEBASING NICOTINE
Industry Knowledge of pH Effect
Perhaps the most eurprismgfmdingin the document review
was the evidence of industry-wide efforts epanningS decades
to alter the chemical form of nicotine to increase the percent
age of freebase nicotine delivered to smokers. Outside the in
dustry, little was known about this; the 1988 surgeon general’s
report has only a 2-page discussion of pH, with most of the dis
cussion focused on buccal absorption of noncigarette tobacco
products.15
1178 JAMA, October 7.1998—Vol 280. No. 13
P.7
Briefly, the chemistry of nicotine is as follows: depending on
pH, nicotine exists as a diprotonated salt, a monoprotonated
salt, or an uncharged or neutral species.78 The salt forms are
sometimes known as the “bound” forms, and the neutral spe
cies are often referred to as the "freebase” or “unbound” form.
As a naturally occurring base, nicotine favors the salt form at .
low values of pH and the freebase form at higher values of pH
(pKi=3.02 and pK2=8.02). Uncharged nicotine transits biologi
cal membranes with considerably less resistance than do the
charged counterparts and affects its physiologic response.
The industry was well aware of these properties. A 1966
BAT report noted:
It would appear that the increased smoker response is associated with
nicotine reaching the brain more quickly.... On this basis, it appears
reasonable te assume that the increased response of a smoker to the
smoke with a higher amount of extractable nicotine [not synonymous
with but similar te free base nicotine] may be either because this nico
tine reaches the brain in a different chemical form or because it
reaches the brain more quickly.”
The report goes on to say that, for both tobacco and smoke,
the higher the pH, the greater the percentage of extractable
nicotine.
A 1971 Liggett memo stated:
'
Increasing the pH of a medium in which nicotine is delivered in
creases the physiological effect ofthe nicotine by increasing the ratio
of free base te acid salt form, the free base form being more readily
transported across physiological membranes. We are pursuing this
project with the eventual goal of lowering the total nicotine present
in smoke while increasing the physiological effect of the nicotine
which is present, so that no physiological effect is lost on nicotine
reduction.1*
A1978 Lorillard document stated, "Furthermore, the ciga
rette brands which are enjoying the largest gales increase
generally have smoke pH’s in the 6.5 to 7.0 range.... Nicotine
in alkaline cigar smoke is more readily absorbed in the lungs
and mouth because of the higher concentration of nicotine in
the free or unprotonated form.”73
Importance of Speed
Industry scientists were well aware of the effect of pH on
the speed of absorption and the physiologic response. A197S
RJR report stated, “Since the unbound nicotine is very much
more active physiologically, and much faster acting than the
bound nicotine, the smoke at a high pH seems to be strong in
nicotine, Therefore, the amount of free nicotine in the smoke
may be used for at least a partial measure of the physiological
strength of the cigarette.”® A. Rodgman of RJR stated in
1980: “ Tree’ nicotine is absorbed more rapidly by the smoker
than is ‘bound* nicotine.”81 Scientists at BAT also were aware
of the pH effect. In a 1964 BAT memo, H. D. Anderson said,
"Nicotine is in the smoke in two forms as free nicotine base
(think of ammonia) and as a nicotine salt (think of ammonium
chloride) and it is almost certain that the free nicotine base is
absorbed faster into the blood-stream."28 Another BAT docu
ment stated, “When a cigarette is smoked, nicotine is released
momentarily in the free-form. In this form, nicotine is more
readily absorbed through the body tissue.”82 A1984 BAT re
port stated, "Nicotine may be presented to the smoker in at
least three forms: (i) salt form in the particulate phase, (ii) free
base form in the particulate phase, (ill) free base form in the
vapour phase. It has long been believed that nicotine present
ed as in (ii)/(iii) is considerably more ‘active? ”®
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By the early 1970s it was recogniied widely throughout the
industry that pH alterations could serve as a means to change
the form of nicotine to a more physiologically active configu
ration. In a 1973 RJR memo, Frank Colby said, “Still, with an
old style filter, any desired additional nicotine 'kick’ could be
easily obtained through pH regulation.”84 In another RJR
memo from 1976, McKenzie said, “The pH also relates to the
immediacy of the nicotine impact As the pH increases, the
nicotine changes its chemical form bo that it is more rapidly
absorbed by the body and more quickly gives a Sdck1 to the
smoker.”83 A1973 RJR document stated:
Methode which may be used to increase smoke pH and/or nicotine
“kick” include: (1) increasing the amount of (strong) hurley in the
blend, (2) reduction ofcasing sugar used on the barley and/or blend, (8)
use ofalkaline additives, usually ammonia compounds, to the blend, (4)
addition of nicotine to the blend, (5) removal of acids from the blend,
(6) special filter eyatejns to remove adds from or add alkaline materi
als to the smoke, and (7) use of high air dilution filter systems. Meth
ods 1-3, in combination, represent the Philip Morris approach, and are
under active investigation.*
Chen at Lorillard in 1976 stated, “If the desired goal is de
fined to be increased nicotine yield in the delivered smoke,
there appear to be only two alternatives: either increase the
absolute yield of delivered nicotine, or increase the pH, which
increases the ‘apparent’ nicotine content without changing the
absolute amount.”87
Ammonia and pH Manipulation
The predominant form of nicotine that is transported within
the alveolar space to the alveolar walls is the freebase form in
the gas phase. The time scales for particle deposition and sub
sequent nicotine transport directly from particle to alveolar
membrane are much too long to play any major role in nicotine
uptake. This explains why exhaled smoke particles are essen
tially depleted ofnicotine. The nicotine leaves the aerosol drop
lets in its volatile or freebase form, a phenomenon known as
“off gassing.” This process is enhanced by increases in pH and
by aerosol dilution. Aerosol dilution occurs as smoke is taken
into the lungs and is increased by cigarette ventilation. By the
mid-1980s all the major cigarette manufacturers were en
gaged in pH manipulation of cigarette smoke, and this was
seen as a way to compete in the marketplace. In a 1989 B&W
document, Johnson says, “AT [ammonia technology] is the key
to competing in smoke quality with PM [Philip Morris] world
wide. All U.S. manufacturers except Liggett [it is known from
vhe documents we reviewed that Liggett has used ammonia
technology] use some form of AT on some cigarette prod
ucts.”88 Philip Morris commenced use ofammonia in their Marl
boro brand in the mid-1960s, and it subsequently emerged as
the leading national brand. Reverse engineering by Philip
Morris’s competitors eventually led each one to the conclusion
that ammoniation in some form was “the secret of Marlboro.”89
Perhaps the most insidious aspect of ammonia technology
was the recognition in the industry that the FTC testing
method for determining “tar” and nicotine in smoke could be
made meaningless. Not only does the testing method fail to
accurately reflect a smoker's tar and nicotine intake, the
method only measures the nicotine in the particulate or aero
sol phase and is incapable ofassessing the “form,” ie, bound or
freebase, in which nicotine exists, Schori, in a 1979 B &W docu
ment, stated, “This suspected relationship between free nico
tine concentration and smoke impact implies that we could
JAMA. October 7. 199B—Vol 200, No. 13
NO.136
P. 8
create a ultra-low tar cigarette that produces much more im
pact than its delivery would suggest.”8* Further understand
ing of this was evident in another B&W document from 1984:
The amount ofnicotine in the vapour phase can be modified by chang
ing the acidity (pH) ofthe smoke. Hence it is readily feasible to have two
cigarettes which deliver the Eiine amount of nicotine (as measured on
A Cafribridge pad [the FTC method]) but which are easily differentiated
on the sensory basis of impact since the aridity of the smoke (and hence
amount of nicotine in the vapour phase) is different,*’
Woods and Harllee from RJR also were aware of this
concept as early as 1973: “The FTC 'tari and nicotine has
decreased for all brands studied at about the same rate. Thus,
all the brands have about the same FTC ‘tar’ and nicotine, but
the Marlboro and Kool are stronger due to a higher smoke
pH.”00 In a 1980 B&W document, Gregory stated:
It appears that we have sufficient expertise available to ‘build’’ a low
ered mg tar cigarette which will deliver ae much '‘free nicotir^e’, as a
Marlboro, Winston or Kent without increasing the total nicotine
delivery above that of a “Light” product There are products already
being marketed which deliver high percentage “free nicotine” levels
in smoke, i.e. Merit, Ncw.tl
The race to incorporate ammonia technology in cigarettes as
a means to manipulate the form ofnicotine into a configuration
that not only “fooled” the FTC test but presented the smoker
with a more potent nicotine ‘‘kick” was driven by Bales and
market share. Indeed, when all was said and done, the data
showed that the predominant correlating variable for brand
sales was free nicotine.82 A 1973 RJR document explained:
AU evidence indicates that the relatively high smoke pH (high alka
linity) shown by Marlboro (and other Philip Morris brands) and Kool
is deliberate and controlled- This has raised questions as to: (1) the ef
fect of higher smoke pH on nicotine impact and smoke quality, hence
market performance, and (2) how the higher smoke pH might be
accomplished.88
Graphs in this document; plotted sales vs pH vg freebase
nicotine for Winston and Marlboro; the graphs show that
Marlboro sales increased as the pH and percentage of freebase
nicotine increased for the years 1955 through the early 1970s.
Additional evidence of the industry’s investigation into pH
manipulation comes from a 1994 Philip Morris document:
To illustrate, a study was conducted on nicotine aerosols, ■where sub
jects inhaled the fiame amount of nicotine atpHs of5.6,7.’5 and 11X3. It
was found that higher peak concentrations of nicotine in blood were
achieved at higher pHs. Since the amounts ofinhaled nicotine were the
same, the results indicate that the higher the pH, the more rapidly
nicotine enters the bloodstream?8
Ammonia compounds are among the most abundant addi
tives used in the manufacture of cigarettes in this country. The
industry contends that ammonia compounds are added for
taste, not to “freebase” the nicotine. However, neither the sci
ence nor internal industry documents support that contention.
The chemistry and physics of aerosol transport and dilution and
the rapid diffusion of the various forms of nicotine within the
aerosol particles and within the alveolar gas spaces provide the
stark reality of why pH manipulation of nicotine is so powerful
CONCLUSION
The strategy of creating doubt about tobacco’s health risk
and attempting to deceive the*public continues today. In a
deposition taken for the Minnesota trial, T. S. Osdene, a re
tired senior scientist for Philip Morris, pleaded the Fifth
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Amendment more than 100 times when presented with Philip
Morris internal documents. Publicly, Mr Geoffrey Bible, the
current chief executive officer of Philip Morris, is quoted to
have urged Osdene to tell the truth end not plead the Fifth
Amendment; “First and foremost, the company wants the
truth told.”®4 Because Osdene did not testify, there are many
truths we can only wonder about For example, what is the
truth about a handwritten note from Osdene regarding Philip
Morris and its research in Cologne, Germany, in which he
wrote, “Ship all documents to Cologne. We will monitor in
person every 2^ months. If important letters or documents
have to be sent, please send to home—I will act oh them and
destroy.”95 While wg can call for honesty and truth from the
industry,90 is it possible that after so many decades of deceit,
the meaning of the word tndh has been forgotten?
The Minnesota tobacco trial represented a pivotal point for
our country as it relates to the tobacco industry. The documents
cited herein are a small but representative sample of those re
viewed and entered as evidence in the trial.-A more complete
set of documents can be accessed on the Internet (www
jTmbluecrosstobacco.com) or at the Minnesota Depository (a
facility how open to the public that contains all 88 million pages
previously secret tobacco industry documents that were
^WJurned over to the state in this trial), The document topics range
from marketing to youth to industry lawyer involvement in
directing research to the industry’s insidious influence on the
political process. These documents are just as disconcerting as
the ones we reviewed. There must be no doubt that the industry
engaged in a major effort to mislead the public and, for over 40
years, has had an elaborate public relations scheme to create
doubt and controversy about the health risks of cigarettes. That .
the industry knew ofthe addictiveness of nicotine and perpetu
ated that addiction through manipulation of nicotine is clear
from the documents we reviewed.
What would constitute effective public health policy toward
the tobacco industry? We agree with others that this is the
time for full disclosure and full accountability and not "settle
ment” according the industry limited liability and immunity.14
We urge a substantial tax increase (to reduce youth initiation
of smoking) of at least $1.50 per pack; revenue from this tax
should be devoted to tobacco control efforts (multimedia coun
teradvertising, education, and research) and treatment initia
tives that would protect our children and benefit current smokrs, following the lead ofSuccessful programs in California and
Massachusetts. We further recommend stringent Food and
Drug Administration control of cigarette design, marketing,
and promotion. In addition, proposed legislation must not in
clude provisions that allow the industry to continue to label
and promote their "light” and “low-tar’’ products, thus con
tinuing the low-tar, low-nicotine scam. Finally, the industry
should be prohibited from imposing their sophisticated adver
tising and promotion techniques on citizens of other nations.
The tobacco pandemic has already spread far beyond US
shores, and every effort must be made to curtail it,
When the breadth and depth oftobacco industry actions are
understood, it becomes evident that allowing a tobacco settle
ment that honors the industry demands for legal and financial
immunity would be a public health disaster of epic proportions
and would allow the industry to continue to promote its deadly
product throughout the 21st century. Congress must use its
power to stop the carnage of more than 400 000 Americans
dying each year of cigarette-related diseases. That is the
’ *
‘
1180 JAMA. October 7.109&—Vol 280, No. 13
P.9
equivalent of 8 fully loaded 747 aircraft crashing daily for 365
days a year with no survivors. Were that to be occurring, does
anyone seriously doubt that Congress would act decisively?
The important question is, does Congress have the conscience
and the political will necessary. We can only hope so. The
heAlfh of millions depends on it
We would like to Acknowledge Attorney GenArd Hubert H. Humphrey III,
who stood by his principles for full disdoeure and full accountability, and
Michael Ciresiand Roberta Walbura for their legal brilliance and indeferigable
work ethic that brought about the successful concliiHkjn of the trial and the dis
closure of the industry documenta. We also want to thank Rhonda Baumberger
for the preparation of the manuEcripL
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BAT, April 17-May 12,1958. Trial exhibit 11028.
23. Knopick PC. Memo to W. Kloepfer, Tobacco Institute, September 9,1980.
Trial exhibit 14303.
24. Ellis C. The effects of smoking; proposal for farther research contracts with
Battelle, BAT, February 13,1962. Trial exhibit 11988.
25. HenningfieldJE, Keenan RM. Nicotine delivery kinetics and abuse liability.
J Consult Clin Paychok lBB2fil:743-7B0.
26. Anderson HD. Potasaiuni carbonate. Memo to R, P. Dobson, BAT, August
7,1964. Trial exhibit 10356.
27. Pander F. The Roper proposal Memo to H. Komegay, Tobacco Institute,
May 1,1972. Trial exhibit 20987.
23. Nowland Organization Inc. SHF Ciffaretic MarhctpLucB Opportunitiet
Search and Situation A^dtf^is, II: Mc^U^cmcni Report Lorillard, December
1976. Trial exhibit 17904.
29. Dunn WL Jr. Jet’s money offer. Memo to Dr H. Wakeham, Philip Morris,
February 19,1969. Trial exhibit 10539.
30. Osdene TS. Memo describing a CTR meeting, Now York City, January 5,
1978, Philip Morris, January 10,1978. Trial exhibit 10227.
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3L Steele HD. Future consumer reaction to nicotine, Memo to M. J. McCue,
B&W, August 24,1978. Trial exhibit 13677.
32. MeDman AJ. Project recommendatione. Memo to R A Bloti, B&W, March
25,1983. Trial exhibit 13344.
33- OldmanM. Cigaretteamoldng.health.and dissonance (Project Libra), BAT,
October 18,1979. Trial exhibit 11102.
34. Spears AW. Lorfllard, November 13,1973. Trial exhibit 14009,
85. Benowitz NL, Henningfield JE. Establishing a nicotine threshold for ad
diction. N Engl J Med. 1994;331:123-125.
36. Smith RE. Memo to J. R Ave, J. G. Flinn! and A. W. Spears, Lorillard,
February 13,1980. Trial exhibit 10170.
37, Laurene AH. Possible TETprujects. Memo to M.Eenkus, RJR, May 24,1971.
Trial exhibit 12777.
88. Brooks GO. Smoker compensation study. Memo to William Telling, BAT,
April 7,1982. Trial exhibit 13668,
39. Creighton DE. Compensation for changed delivary. BaT, June 27, 1978.
Trial exhibit 11089.
40. Green SJ. The product in the early 1980s. BAT, March 29,1976. Trial exhibit
11386.
4L Schumacher S. Nicotine and amoker satisfaction. RJR, 1977. Trial exhibit
12790,
42. Dunn WL Jr. High nicotine, low TPM cigarettes. Memo to R. B. Seligman,
Philip Morria, March 24,1980. Trial exhibit 10529.
43. Dunn WL Jr. Motives and incentives In cigarette smoking. Philip MorriS|
1972. Trial exhibit 180B9.
44- Teague CE Jr. The nature of the tobacco busineaB and the crucial role of
nicotine therein. Research planning memorandum, RJR, April 14,1972. Trial
exhibit 12408.
45. McCormick AD. Smoking and health. BAT, May 8,1974. Trial exhibit 10602.
46. Oedene TS. Evaluation of major R&D programs. Letter to R. B, Seligman,
Philip Morris, August 12,1980, Trial exhibit 10255.
47. Roberts DL. Memo to Flavor and Biobehavioral Divisions regarding brain
storming session, RJR, October 13,1083. Trial exhibit 12748.
48. Reuter B. Table, Philip Morris, circa 1992. Trial exhibit 11559.
49. Johnson RR. Comments on nicotine, B&W, 1971. Trial exhibitJ3878.
50. Crellin RA, Ferris RP, Greig 0, MHner JK, Brainstorming H: what three
radical changes might, through the agency of R&D, take place in this industry
by the end of the Century? BAT, April 11,1980. Trial exhibit 11361.
5L Griffith RB. Letter to John Kirwan, B&w, September 18,1963. Trial exhibit
10856.
52. R&D views on potential marketing opportunities. BAT, December 9,1964.
Trial exhibit 11275.
53. Guess HE. Winston B nicotine control. Memo to J. L. McKenzie, RJR, Feb
ruary 5,1980. Trial exhibit 18182.
54. Ayres CI. Proceedings of the smoking behavior marketing conference, eb&aion IJL Noteo from the GR&DC Nicotine Conference, B&W, July 9-12,1984.
Trial exhibit 13421,
55. Slaven RW, A progress report on nicotine migration and manipulation.
LorDJard, February 25,1982. Trial exhibit 10019.
56. Pepples E. Memo to I. W. Hughes, B&W, 1977. Trial exhibit 26210.
57. RJR/Biosource genetics: joint research agreement, RJR, 1992. Trial exhibit
13222.
58. Y1 product B&W. Trial exhibit 13671.
59. Benowitz NL, Hall SM, Heming RI, Jacob P HI, Jones RT, Osman A-L.
Smokers of low-yield cigarettes do not consume less nicotine. N Engl J Med.
19S3^09d 39-142.
60. Robinson JE. Critique ofsmokers oflowyield cigarettes do not consume leas
nicotine. To A. Rodgman, RJR, July 25,1983. Trial exhibit 12648.
6L Robinson JH. Pritchard WS. The meaning of addiction: reply to West, Psychopharmacology. 1992;108:411-416.
62. Smoking and health: aignificance of the Report of the Surgeon General’s
Committee to Philip Morris Incorporated. Memo to Dr H, Wakehara, Mr Hugh
Cullman, Philip Morris, February 18,1964. Trial exhibit 10322,
63. Short R. A new product BAT, October 21,1971. Trial exhibit 10306.
64. Greig CC. Structured creativity group, thoughts by C. C. Greig—R&D
Southampton marketing scenario, l;low CO product; 2: high expanded tobacco
cigarette. BAT, early 1970s. Trial exhibit 10683.
65. Goodman B. Marlboro-Marlboro Lights study delivery data. Report to L.F.
Meyer, Philip Morris, September 17,1975. Trial exhibit 11564.
66- Wood DJ. Smoking products research. BAT, January 19,1977. Trial exhibit
11203.
67. Short PL. Smoking and health item, 7; the effect oh marketing. Memo to
Fred Haslam, BAT, April 14 and 28,1977. Trial exhibits 10584 and 10585.
NO.136
P. 10
P^ucta/consumer interaction: the role of human smoking stud
ies In suqjectjre testing, with particular reference tc machine vb. human 8mol>
ing. BAT, May 19, ipfiL Trial axhibit 11357.
6?. Centers for Disease Control find Prevention. Filter ventilation levels in
sdwted U£. dgarettes, 1997. MMWR Mart Afartal Wkly R^. 1997;4fclM370. Kozlowski LT, Goldberg ME, Yost BA, Ahern FM, Aronson KR, Sweeney
CT. Smokers are unaware of the Citer events now on most dgartttc^ results of
a national survey. Tofc ControL 1996j5i6S^70.
7L US Department of Health and Human Services. The FTC Cigarette Test
Method for Determining Tetr, Nicotine, and Carbon Monoxide Yieldi of US.
Cigarettes: Report ofthe NCJExpert Cammittse. Washington, DC; US Dept of
Health and Human Services, Public Health Service, National Infititutee of
Health; August 1996. NTH publication 96-402S.
72. Townsend D. Deposition of David Totmeend, jn the Circuit Court, 4th Ju
dicial Circuit, Duval County, Florida, Case No. 9501S2tKCA, Division CV-C.
Jean Connor, plaintiff vs R. J. Reynolds Tobacco Company, etc, et al, defen
dants. October a, 1994:1-102. Cited by. Koalowski LT, Goldberg ME, Yost Ba,
Ahem FM, Aronson KR, Sweeney CT. Smokert are unaware of the filter events
now on most cigarettes: results of a nationaJ survey. Tab Control. 1896^26572. Hirji T. Effect of ventilation on tar delivery. To A- L. Heard, BAT, July 23
1987. Trial exhibit 12110.
74. Graen ST. Suggested questions for CAC III. BAT, August 26,1977. Trial
exhibit 11890.
To. US Department of Health and Human Sendees. Ths Health Cansequences
ofSmoking: Nicotine Addiction: A Report ofthe Surgeon General, IMS. Wash
ington, DC: US Dept of Health and Human Services, Public Health Service,
Centers for Disease Control, Office on Smoking and Health; 1988, Publication
CDC 88-8406.
76- Creighton DE’. The significance of pH in tobacco and tobacco amoke. Report
issued by T Hirji, BAT, June 1988. Trial exhibit 12223.
77. Blackhurfet JD. Further work on ‘’extractable" nicotine. Report issued by L
W. Hughes, BAT, September SO, 1966. Trial exhibit 17825.
78. Williams RL. Development ofa cigarette with Increased amoke pH. Liggett,
December 16,197L Trial exhibit 11903.
79. Ihrig AM. pH of particulate-phase. Memo to C. L. Tucker, Jr, LoriHard,
February 8,1973. Trial exhibit 10095.
80. Woods JD, Harilae GC. Historical review of smoke pH data and sales
trends for competitive brand filter cigarettes. RJR, May 10,1973. Trial exhibit
12337,
Bl. R odgman A. Clarification ofmy O7Z22Z8O memo on nicotine additives. Memo,
RTR, September 8,1980. Trial exhibit 13212,
82. Cigarette design. BAT, undated document Trial exhibit 11973.
83. Riehl T, McMurtrie D, Heememi et *L Project SHIP: review ofprogress,
November 6-8,1984. BAT, November 12,1984. Trial exhibit 10752,
84. Colby FG. Cigarette concept to assure RJR a larger segment ofthe youth
market. Memo to R A. Blevins,Jr, RJR, December 4,1973. Trial exhibit 12464.
85. McKenzie JL. Product characterization definitions and impEeations. Memo
to A. P. Ritehy, RJR, September 21,1976. Trial exhibit 12270.
86. T eague CE. Implication b and activities arisingfrom eomdstion of smoke pH
with nicotine impact, other amoke qualities, and cigarette sales. RJR, 1978. Trial
exhibit 18155.
87. Chen L. pH of smoke: a review. Lorillard, July 12,1976. Trial exhibit 10110.
88. Johnson RR. Ammonia technology conference minutes, Louis viHe, Ky, May
18-1S, 1969, B&W, June 12,1989. Trial exhibit 13Q69.
89. SchoriTR Free nicotine; itsimplicationonamoke impact.B&W, October22,
1979. Trial exhibit 2590.
90. Prowedings ofthe Bmokingbeha*itt--maricBtmgconference, July9-12,1984,
seamon I. To Dr L. C. F. Blackman and Mr A. M. Heath, B&W, July 80,1984. Trial
exhibit 13430.
BL Gregory CF. Observations of free nicotine changes in tobacco smoke/#528.
B&W, January 4,1980. Trial exhibit 13182.
92. Woods JD, Sheets SH. Smoke balance factors and control: RDM report #4.
• PJR, January 15,1975. Trial exhibit 12340.
93. The effects of cigarette smoke “pH” oh nicotine delivery and sulyective
evaluations. Philip Morris, June 24,1994. Trial Exhibit 11752.
94. Shaffer D. Ex-tobacco researcher takes Fifth during trial. St Paul Pioneer
Press. February 14,1996. Available at httpy/tnvw.pioneeiplanetcom/archive/
tobac_ Accessed: Aogust 10,1998.
98. Ofidene TS. Undated handwritten note. Trial exhibit £501.
96. Report qf the Scientific Committee On Tobacco and Health. London: De
partment of Health (United Kingdom); March 1998:9-10. (
JAMA, October 7, 1996—Vol 200, No. 13
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KlOlO
WORLD
REGIONAL OFFICE FOR
HEALTH
SOUTH-EAST ASIA
ORGANIZATION
Draft
R
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G
O
N
A
L
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Io
Summary Report
REGIONAL COMMITTEE
SEA/RC52/DSR-1
Fifty-second Session
6-11 September 1999
7 September 1999
6 SEPTEMBER 1999 - 9.30 A.M. TO 5.00 P.M.
and
7 SEPTEMBER 1999 - 9.00 A.M. TO 12.30 P.M.
TABLE OF CONTENTS
2
INAUGURATION............................................................................................
Address of Welcome by Secretary, Ministry of Health and Family Welfare,
Government of Bangladesh....................................................................
Address by the Regional Director, WHO.....................................................
Address by the Director-General, WHO......................................................
Address by State Minister for Health and Family Welfare, Bangladesh......
Address by the Minister of Health and Family Welfare, Bangladesh..........
Inaugural Address by the Prime Minister of Bangladesh............................
Vote of Thanks............................................................................................
OPENING OF THE SESSION (Agenda Item 1).............................................
2
2
3
3
3
4
4
SUB-COMMITTEE ON CREDENTIALS (Agenda item 2)
4
ELECTION OF CHAIRMAN AND VICE-CHAIRMAN (Agenda item 3)
4
ADOPTION OF PROVISIONAL AGENDA (Agenda item 4) (document SEA/RC52/1)
4
ADDRESS BY THE DIRECTOR-GENERAL, WHO (Agenda item 6)
5
DRAFTING GROUP ON RESOLUTIONS
6
u
THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION REPORT OF THE REGIONAL DIRECTOR FOR THE PERIOD
1 JULY 1997 - 30 JUNE 1999 (Agenda item 5) (documents SEA/RC52/2,
SEA/RC52/lnf. 1 and Inf. 2)............................................................................
6
M
ADDRESS BY CHAIRPERSON OF SEA/ACHR
10
M
M
|i I
T
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E
D
O
C
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2
STATEMENT BY REPRESENTATIVE OF NONGOVERNMENTAL
ORGANIZATIONS..........................................................
11
SEA/RC52/DSR-1
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INAUGURATION
Address of Welcome by Secretary, Ministry of Health and Family Welfare,
Government of Bangladesh
MR M.M. REZA, Secretary, Ministry of Health and Family Welfare, welcomed the Chief
Guest, Her Excellency Sheikh Hasina, Prime Minister of Bangladesh, and other dignitaries.
He said that the Regional Committee was being held in Bangladesh after a gap of 17 years
and since then, considerable improvements had taken place in the field of public health.
WHO had provided technical and financial assistance for health development, particularly in
the battle against polio and communicable diseases, such as malaria, tuberculosis and HIV.
The country had adopted a sectoral management programme for reforming health system
structures and functions to help reduce expenditure and improve the health of the people,
particularly the poor. He underscored the importance of ensuring access to existing drugs
and medicines as well as the development of new ones to counter major killer diseases. He
looked forward to new directions from the Regional Committee for effectively dealing with
health problems in the country.
Address by the Regional Director, WHO
DR UTON MUCHTAR RAFEI, Regional Director, highlighted the collaborative activities in
Bangladesh, and referred to WHO’s support for improving the health of the people,
particularly mothers, children and the poor. WHO had been closely involved with the
government in tackling the problem of arsenic contamination of drinking water in some areas
and ensuring the safety of blood and blood products, which assumed greater significance in
the context of the problem of HIV/AIDS.
WHO’s united approach, in partnership with other UN Agencies and nongovernmental
organizations, had resulted in significant gains in the fight against vaccine preventable
diseases, including polio, through synchronized National Immunization Days by several
countries of the Region. Multidrug therapy (MDT) for leprosy control, the DOTS strategy
against TB and the use of impregnated bednets in malaria control were some of the key
approaches in WHO collaborative activities. However, the challenges posed by the growing
population, high maternal mortality and HIV/AIDS, TB, malaria as also noncommunicable
diseases, avoidable blindness and malnutrition still needed attention. Considering the global
economic scenario, WHO needed to be increasingly effective and efficient as well as to
prioritize and focus its support to countries.
Reiterating that health should be treated as central to development, Dr Uton called for
continued collaboration from the Member Countries to enable WHO strengthen its
partnership with development partners to ensure that the benefits of cooperation with WHO
reached people who had been neglected for long.
Address by the Director-General, WHO
DR GRO HARLEM BRUNDTLAND, Director-General, WHO, said that the Organization’s
decentralized structure was one of its strengths. WHO drew upon the experiences of all
regions and Member Countries. WHO was committed to fight poverty and to promote equity
of access of health benefits to all. Though the South-East Asia Region faced many
challenges, she believed that it had the resources and the ability to overcome them.
SEA/RC52/DSR-1
Page 3
Referring to the important role played by WHO in health development in the Region, Dr
Brundtland visualized its continued role as adviser, supporter, catalyst and partner for
ensuring the health of those in greatest need. She sought the cooperation of the Member
Countries in fulfilling WHO’s noble task. She said that as part of the United Nations
Development Group, WHO would actively promote coordination and planning with
collaboration from other UN Agencies.
Address by State Minister for Health and Family Welfare, Bangladesh
PROFESSOR DR M. AMANULLAH, Minister of State for Health and Family Welfare,
expressed the hope that the outcome of the Regional Committee meeting would help to
develop future health programmes in Bangladesh with intensified WHO collaboration.
Briefly outlining the health programme activities in the country, he said that many of the
benefits from advances in medical technology were yet to reach the third world countries.
Though there had been improvements in health infrastructure development, problems of
poverty, illiteracy, malnutrition and communicable and noncommunicable diseases had yet
to be dealt with. Simultaneously, there was the danger posed by emerging killer diseases,
such as HIV/AIDS. He referred to arsenic contamination of drinking water in Bangladesh and
sought WHO’s support in dealing with this problem. He cautioned against the arms race, and
particularly the disastrous effects of the use of nuclear weapons. Bangladesh had embarked
on a Health and Population Sector Programme using a comprehensive sector-wide
approach for the provision of health care services. There had been increased participation of
women in social development activities and local government bodies.
Address by the Minister of Health and Family Welfare, Bangladesh
MR ALHAJ SALAH UDDIN YUSUF, Minister of Health and Family Welfare, thanked WHO
for holding the meeting in Bangladesh and said that he looked forward to sharing the
experiences of other Member Countries regarding health development activities. Though
there had been overall improvement in the health situation in the country, challenges posed
by communicable diseases, malnutrition and emerging and re-emerging diseases needed to
be met. At the same time, there had been underutilization of the health infrastructure,
particularly at the Thana level. Provision of basic health services to the entire population,
particularly the underserved, had been a national goal. The Health and Population Sector
Programme, launched in July 1998, was a positive step in this direction. He identified
investment in health and human resources development as one of the critical areas and
sought the support of development partners in this regard. The Global initiatives of the WHO
Director-General, such as Roll Back Malaria, Tobacco Free Initiative and Tuberculosis
Control, were in line with the priorities of Bangladesh. He also referred to the difficulties
caused by natural calamities and disasters and underlined the need to strengthen the
country’s capacity and capability to effectively deal with these.
Inaugural Address by the Prime Minister of Bangladesh
HER EXCELLENCY SHEIKH HASINA, Prime Minister of Bangladesh, welcomed the
dignitaries and thanked WHO for holding the Regional Committee session in Bangladesh.
WHO’s assistance in meeting the needs of the developing countries, especially in enhancing
the national capacity building process was much appreciated. She considered health sector
reforms as an inevitable process of change leading to wide-ranging improvements in policy
and strategic issues. Countries needed to adjust their policies and strategies according to
the changing needs brought about by the advancement of science and technology.
SEA/RC52/DSR-1
Page 4
Tracing the history of Bangaldesh, she said that the various pragmatic programmes
initiated by the Father of the Nation, Bangabandhu Sheikh Mujibur Rahman, had helped the
country achieve notable successes. She specifically referred to enhanced food production, a
reduction in population growth and high couple protection rate, increased life expectancy,
and development of the health infrastructure. Of particular importance was the introduction
of the Health and Population Sector Programme (HPSP), a package encompassing
reproductive health, child health, communicable disease control, family planning and limited
curative care at all levels. However, there were formidable health problems owing to
population explosion, poverty, low literacy rate, high maternal mortality and malnutrition,
coupled with a high prevalence of communicable diseases. Re-emerging communicable
diseases, including sexually transmitted diseases and HIV/AIDS, also posed a grave threat.
These issues were being addressed through decentralized administration and a democratic
system.
The Prime Minister highlighted the achievements of her government in reducing infant
mortality rate through oral rehydration therapy through high immunization coverage. The
recently-launched programme of “Education For All by 2006 AD” would go a long way in
increasing literacy, including adult literacy. Concerned with environmental pollution,
legislation had been enacted regarding deforestation and disposal of industrial refuse.
Vote of Thanks
PROFESSOR A.K.M. NURUL ANWAR, Director-General of Health Services, proposed a
vote of thanks.
OPENING OF THE SESSION (Agenda Item 1)
IN THE ABSENCE of the Chairman of the 51st session, Dr U Kyi Soe, Vice-Chairman of the
session opened the 52nd session of the Regional Commiittee, which was attended by the
Director-General of WHO, representatives of Member Countries and other participants and
observers.
SUB-COMMITTEE ON CREDENTIALS (Agenda item 2)
A SUB-COMMITTEE on Credentials, consisting of representatives from Bhutan, DPR Korea
and Nepal was appointed. The Sub-committee met under the chairmanship of Dr Kim Myong
Dok (DPR Korea) and examined the credentials submitted by Bangladesh, Bhutan, DPR
Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka and Thailand. The credentials
were all found to be in order, thus entitling all representatives to take part fully in the work of
the Regional Committee. The report of the Sub-committee (SEA/RC52/15) was approved by
the Regional Committee.
ELECTION OF CHAIRMAN AND VICE-CHAIRMAN (Agenda item 3)
DR M.M. REZA (Bangladesh) was elected Chairman of the 52nd session of the Regional
Committee. Dr Azrul Anwar (Indonesia) was elected Vice-Chairman.
ADOPTION OF PROVISIONAL AGENDA (Agenda item 4)
(document SEA/RC52/1)
The Committee adopted the Provisional Agenda, as contained in document SEA/RC52/1.
SEA/RC52/DSR-1
Page 5
ADDRESS BY THE DIRECTOR-GENERAL, WHO (Agenda item 6)
DR GRO HARLEM BRUNDTLAND said that the Region was capable of meeting the many
challenges it faced. However, the health gains of the past needed to be shared equitably by
all. WHO’s commitment to ensuring better health care to all, particularly the poor, was
relevant to the Region, which comprised one-fourth of the world’s population. Improving the
effectiveness of WHO was high on her agenda. The focus on the most important health
issues needed to be maintained in a spirit of partnership. An area of concern was the
disproportionately high mortality and the burden of diseases in the Member Countries of the
Region.
The Director-General assessed WHO’s work in the South-East Asia Region based on
four global strategic directions. First, mortality and disability suffered by the poor and
marginalized populations needed to be reduced with the focus on the control of
communicable diseases and conditions that led to increased child and maternal mortality.
Attributing the global progress in polio eradication to the efforts of SEAR countries, Dr
Brundtland said that NIDs were the largest public health campaigns covering millions of
children, made possible with the commitment of health workers and volunteers. However,
improved surveillance and additional rounds of NIDs were required.
Reiterating WHO’s commitment to fight HIV/AIDS, and its resolve to eventually develop
a vaccine against HIV, Dr Brundtland lauded Thailand’s leadership in spearheading health
education campaigns and AIDS vaccine trials. The Stop TB Initiative aimed at generating
more resources and partnerships for TB control. Urging Member countries to achieve 100
per cent coverage with DOTS, she emphasized the need for increased surveillance for antiTB drug resistance.
The second strategic direction related to countering potential threats to health resulting
from economic crises, unhealthy environments and risky behaviour. Referring to the arsenic
contamination of drinking water in Bangladesh, she underscored the importance of finding
technical solutions to purify contaminated water as well as to find uncontaminated sources of
water. She called for concerted regional action to support WHO’s global tobacco control
efforts and looked forward to the participation of representatives from SEA countries at the
working group of the WHO Framework Convention on Tobacco Control in October in
Geneva.
Reforms of health systems, health care financing and ensuring health care coverage
formed the third strategic direction. The pre-payment system for health care services placed
less burden on the poor. Member Countries looked forward to WHO for guidance in handling
the issue of rapid growth of private medical care and channelising it for public goals.
The fourth strategic direction concerned the development agenda and recognizing
health as a key to human development and progress. She said that illness was not only a
result of poverty, but could also be a cause of it. Marked improvements in the health status
and increased life expectancy, in turn, could lead to strong economic growth in East and
South-East Asia.
In view of the budgetary constraints, there was a need to shift resources from low to
high priority areas. A series of efficiency measures had been initiated at the global level to
meet this challenge. As a result, SEAR had also to identify budgetary efficiency savings for
the next biennium in order to focus more sharply on priorities. Terming conflict and strife as
the worst enemies of health, she said that these should not negate the benefits of progress
achieved through decades of hard work.
**★
***
***
SEA/RC52/DSR-1
Page 6
The meeting expressed concern at proposed budgetary measures, and felt that savings
should be effected by identifying and improving internal efficiency rather than by imposing
limitations in resource allocations at the country level. Furthermore, the determination of
priority areas to whjich funds would be diverted from efficiency savings should be left to the
countries to decide in consultation with the WHO Regional Office.
Responding, the Director-General clarified that WHO was a technical agency and not a
funding agency. She was responsible to the World Health Assembly, and while the views of
Regional Committees provided valuable perspective, Constitutional provisions and the
ovedrriding roles of the Executive Board and the World Health Assembly were to be
acknowledged. Resources to countries were not being reduced; however, shifts to priorities
were needed. Two-thirds of WHO funds were at country and regional levels. Waste existed
not just at WHO headquarters. The Director-General hoped for country support in
responding to what had been asked of her by the World Health Assembly.
DRAFTING GROUP ON RESOLUTIONS
A DRAFTING GROUP on resolutions, comprising representatives from Bangladesh, Bhutan,
India, Maldives, Nepal and Thailand was constituted. Ms Sujatha Rao (India) was elected
Chairperson of the group.
THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION REPORT OF THE REGIONAL DIRECTOR FOR THE PERIOD
1 JULY 1997 — 30 JUNE 1999 (Agenda item 5)
(documents SEA/RC52/2, SEA/RC52/lnf. 1 and Inf. 2)
INTRODUCING his report for the period 1 July 1997 to 30 June 1999, the Regional Director
referred to the change from input-oriented to a product-oriented approach in programme
budgeting and implementation, which had been introduced in 1996. This approach would
ensure that WHO moved steadily towards a result-oriented managerial process.
Recalling the Regional Committee’s decision on pooling of resources for a
supplementary intercountry programme in 1996-1997 and in 1998-1999, the Regional
Director said that problems common to more than one country could be addressed through
enhanced intercountry activities. In this context, he urged Member Countries to focus on
result-oriented collaborative programmes to meet technical needs for supporting national
health development programmes.
The regional allocation for the biennium 2000-2001 had been reduced by over
$ 3 million compared with 1998-1999 as a result of implementation of resolution, WHA51.31.
The Region now needed to focus its resources in a concentrated manner in order to respond
to the challenges of World Health Assembly resolution, WHA52.20, which called for, among
others, shifting resources out of ineffective areas to higher priorities.
The Regional Director informed the meeting that in keeping with the Director-General’s
call to make the concept of “one WHO” a reality, the structure of the Regional Office was
being reorganized in line with the clusters in WHO headquarters. The new structure was
expected to strengthen opportunities for both intra and interdepartmental teams to jointly
address emerging issues.
Highlighting WHO’s achievements during the reporting period, Dr Uton said that the
Organization had contributed meaningfully to overall health development in the countries.
SEA/RC52/DSR-1
Page 7
Intensified WHO collaborative activities with countries of the Region as well as WHO
initiatives, such as intercountry cooperation for health development, joint planning initiative,
synchronization of National Immunization Days, and coordination of border meetings had
made positive contributions to health development.
WHO had continued to support high-level meetings, such as the Health Ministers
Meeting, the meeting of Health Secretaries and meetings of Medical Parliamentarians, which
had helped to place existing and emerging health development issues high on the political
and development agendas of the countries.
Efforts had been intensified to promote approaches that addressed specific women’s
health issues in the context of women’s lives and their vital role in development. A working
group, constituted in response to the decision of the forty-ninth session of the Regional
Committee, had identified the obstacles in the recruitment and retention of women in
professional posts. Its report would be available to the representatives at the current
session. Specific action on the recommendations of this group was being formulated. The
employment and recruitment of women in decision-making positions in SEARO had risen
from 8-9% in 1993 to over 23% at present. A mechanism had been established to monitor
and improve the induction of women to achieve the target of 30%.
★ ★★
***
★ **
The Committee lauded WHO’s significant contribution in providing critical support for
eradicating guinea-worm disease, reducing the prevalence of leprosy, combating
tuberculosis and HIV/AIDS, and for eradicating poliomyelitis. WHO had provided catalytic
support to countries in mobilizing international funding thereby enabling them to articulate
the health problems and to develop proposals for international funding. As the South-East
Asia Region comprised a vast geographical area and housed almost a quarter of the world’s
population, it also faced the double burden of disease and burgeoning populations. The
Committee therefore hoped that WHO, at all levels, would recognize these factors while
allocating resources for future collaborative programmes.
In order to enable both WHO and Member Countries to assess the impact of WHO
collaborative programmes and their linkage to the overall health and economic development
in Member Countries, the Committee expressed the need for more effective and transparent
monitoring and evaluation systems.
The Committee acknowledged WHO’s significant role in the areas of research, and
development of human resources for health, especially through training and fellowships. It
further noted the possibility of conducting in-country fellowships as well as training of health
personnel at national centres of excellence, which would not only be cost-effective but would
also be mutually beneficial for institutions and countries.
Noting that large investments in clinical aspects alone would not be effective in
controlling diseases, the Committee called for further strengthening of public health
administration in Member Countries through enhanced technical support and increased
allocation of budgetary resources.
The Committee appreciated WHO’s assistance in the control of communicable and
noncommunicable diseases. In particular, the support extended to Member Countries had
helped them to overcome the adverse health impacts of the economic crisis and in
strengthening the health system. The need for WHO’s assistance to sustain health
development programmes and in accessing good quality drugs was stressed.
SEA/RC52/DSR-1
Page 8
The Committee noted that considerable gains had been made in the past few years in
developing strategies for controlling diseases in the border areas, particularly malaria,
through regular border meetings. Along with local preparation of training material, networking
of institutions was required. In this connection, it felt that the field epidemiology training
programmes, developed in some countries of the Region, could be of help to other countries
in enhancing and strengthening their capacities to effectively deal with public health
problems.
The Committee noted that conducting rapid assessment among populations with high
risk behaviour, such as injecting drug users was useful to assess the problem of HIV/AIDS
and for planning interventions for its control. At the same time, HIV/AIDS surveillance,
including on risk behaviour, was important for planning as well as evaluating the impact of
intervention. In this context, the need for intercountry and interagency collaboration and
exchange of country experiences in HIV/AIDS surveillance was stressed. Remarkable
progress had been made in tuberculosis control using the DOTS strategy. Further expansion
of DOTS without compromising the quality is expected in the near future so that goal of
nation-wide DOTS coverage can be achieved in all countries by 2005.
The Committee called for high priority to Integrated Management of Childhood Illnesses
to accelerate reductions in infant and child mortality rates. WHO should provide enhanced
technical expertise and in-service manpower training for achieving this. In countries where
infant mortality rates have declined substantially, WHO should support programmes to
reduce mortality in the neonatal period.
The Committee noted that WHO continued to promote an integrated preventive
approach to address the increasing incidence of cardiovascular and cerebrovascular
diseases, malignancies, metabolic and degenerative disorders and mental illness. Efforts
had been made to increase public awareness and to strengthen programme management
capabilities for PHC personnel.
Technical support was provided to countries in developing basic eye care and ear care
services. Plans were being made to launch Regional Vision 2020 on the lines of Global
Vision 2020, launched by the Director-General early this year.
WHO was striving to raise the standards of reporting and surveillance through support
to field epidemiology training programmes in India, Indonesia and Thailand.
Member Countries had been supported in operationalizing the regional strategy for
reproductive health, with special focus on reducing maternal mortality. Significant technical
support had been provided to the countries in the areas of mental health, substance abuse,
nutrition, environmental health, essential drugs and traditional medicine through innovative
approaches.
In its fight against tobacco, WHO’s focus had been on reducing consumption levels and
prevent initiation to tobacco use. A Regional Policy Framework and Plan of Action, which
would be a blueprint for the control of tobacco use, had been developed. Tobacco Free
Initiative had been included as a priority project in the intercountry programme in 2000-2001.
The Committee was concerned that the shift from component-based approach to
product-oriented approach had caused some confusion for country programme managers in
the preparation of plans of action. It however, noted that the Regional Office had organized
workshops on programme development and management to orient staff and nationals on the
planning process.
SEA/RC52/DSR-1
Page 9
The Committee stressed the need to reflect in the Regional Director’s biennial report,
important policy issues regarding the improvement of efficiency in WHO as well as problems
and constraints faced by WHO in collaboration with the Member States. It noted that a
working group had been established to study the effectiveness of WHO collaborative
programmes in the countries and the Regional Office, which was expected to make its
recommendations.
The Committee noted that intensified WHO collaborative activities with countries of the
Region as well as WHO initiatives, such as intercountry cooperation for health development,
joint planning initiative, synchronization of National Immunization Days, and coordination of
border meetings, had made positive contributions to health development.
The Committee’s attention was drawn to new and emerging health problems and
challenges resulting from global warming and climatic changes. The need was expressed for
the Member Countries and WHO to formulate effective strategies to address these.
The Committee also urged Member Countries to consider implementing the
international plan of action endorsed by the 51st World Health Assembly for the prevention of
violence and injury, which caused a major drain on national resources by way of medical
treatment and rehabilitation of the victims.
The Committee expressed the need to support cost containment measures in the
countries, particularly in respect of drugs and medicines, to make them affordable to the vast
majority of the population. It underscored the need for the procurement of diagnostic
material, such as test kits, drugs and insecticides to deal with malaria and kala azar.
Preparation of training material, particularly their translation into local languages was no less
important.
Considering that the countries lacked expertise in health legislation, the Committee
emphasized the need to evolve health legislation and regulatory framework. The implications
of agreements such as WTO/GATT, TRIPS, on health should be kept in mind. Herbal drugs
were acknowledged to have an important role in treatment. A multisectoral approach
involving the pharmaceutical industry and other relevant nongovernmental organizations was
called for in this regard. Clinical research in this area also needed to be supported.
In the area of food safety, the Committee recognized the need to develop closer
cooperation with other UN, bilateral and multilateral agencies. Protection of the consumer
was equally important.
The Committee underscored the importance of rational use of insecticides for the
control of communicable diseases as well as in agriculture. The broad area of surveillance
covered assessment of the problem as well as the behavioural aspects. There was a need to
analyse surveillance data and provide feedback to help implement specific activities. It felt
that the Member Countries should develop disaster preparedness and early warning
systems in order to effectively deal with epidemics, as well as natural calamities.
The Committee recognized the need for increased focus on health promotion. WHO
had provided assistance in developing health promoting schools, in line with the
recommendations made by the Meeting of Health Ministers. At the same time, significant
steps had been taken by the countries in the area of mega country initiatives. There was,
however, a need to speed up activities since health promotion formed an integral part of
control of communicable and noncommunicable diseases. The Committee felt that a strong
national network was necessary to develop an even stronger regional network in health
promotion activities as a whole. Realizing the importance of healthy cities, Member countries
had initiated action for strengthening this programme.
SEA/RC52/DSR-1
Page 10
The Committee was informed that the Advisory Committee on Health Research had
deliberated on the important areas of development of clinical research activities, promotion
of herbal and traditional systems of medicine, participatory development process in strategic
planning, and research on regulatory system development. It noted that appropriate
guidelines in these areas were being developed by the Scientific Working Groups set up by
the SEA/ACHR.
The Committee noted the serious problem of arsenic contamination of drinking water in
shallow tubewells in some countries of the Region, leading to skin cancer and kidney failure.
It recognized the need to train health workers in the treatment of arsenic-affected patients.
The need to develop a comprehensive workplan enlisting a high level of political commitment
was emphasized. The Committee urged that alternative approaches, such as chemical
treatment of contaminated water be explored.
A resolution on the Regional Director’s report was adopted (SEA/RC52/R—).
ADDRESS BY CHAIRMAN OF SEA/ACHR
DR M.P. SHRESTHA, Chairman, South-East Asia Advisory Committee on Health Research,
presented the conclusions and recommendations of its twenty-fourth session, held in April
1999. The SEA/ACHR had recommended, among other things, continued interaction
between the regional ACHR and directors of Medical Research Councils for defining the
scope and content of national and regional health research agendas, strengthening of health
research capacity and information management and enhancement of the roles of WHO
collaborating centres and national centres of expertise. It had also stressed the need for
monitoring and evaluation of health research. Noting that there were relatively few research
activities on health policy development, it had called for the development of good linkages
between researchers and policy-makers and greater intersectoral collaboration.
While reviewing the progress in the implementation of the recommendations of the first
joint session of the SEA/ACHR and MRCs held in 1998, the SEA/ACHR had recommended
that national health or medical research councils should be closely involved in monitoring
and evaluation.
In its review of important global research programmes, the Committee endorsed the
proposal to broaden the mandate of the Special Programme for Research and Training in
Tropical Diseases (TDR) with the addition of tuberculosis and dengue/dengue haemorrhagic
fever and directed that a comprehensive regional plan for the prevention and control of
malaria in border areas be developed. It recommended the formation of a task force and
development of a regional framework to review national ethical guidelines under the Special
Programme of Research, Development and Research Training in Human Reproduction
(HRP). It also requested the WHO Regional Office to convene a task force for reviewing
research needs in the prevention and control of HIV/AIDS in the Region.
The 36th session of the WHO Global Advisory Committee on Health Research called for
adequate reflection of the needs and priorities of the Region in its global agenda and felt that
the regional and global ACHR system, including annual meetings of the Committee, should
be maintained. The need to enhance partnerships in health research with suitable
organizations and institutions, including NGOs, was stressed. The mission statement and
strategic plan for global and regional health programmes on evidence and information for
policy should clearly define and delineate the role of WHO in health research at all levels. In
view of the importance of vaccine research in disease control, it felt that the Regional Office
should explore strategic ways of enhancing intercountry cooperation in the areas of vaccine
production, research and delivery. Based on the recommendations of the SEA/ACHR,
SEA/RC52/DSR-1
Page 11
scientific working groups had been established for the formulation of national health
research policies and strategies; criteria for health research priority-setting; management of
health research information and mechanisms for coordination of health research activities. It
was expected that this would result in the development of a framework to evaluate the
implementation of plans of action based on region-specific guidelines.
STATEMENT BY REPRESENTATIVES OF NONGOVERNMENTAL
ORGANIZATIONS
PROF. QUAZI SALAMATULLAH (International Council for Control of Iodine Deficiency
Disorders (ICCIDD) said that iodine deficiency was the most common preventable cause of
brain damage and his Organization was engaged in the sustainable elimination of these
disorders. He congratulated the Director-General of WHO on her excellent report on iodine
deficiency and its control, which described the spectacular progress achieved in this area.
ICCIDD considered filling the gaps in terms of implementation of correction of IDD, ensuring
quality assessment and monitoring of programmes and guaranteeing the sustainability of the
ongoing programmes as the future needs in this area.
DR SANJEEB SAPKOTA (International Federation of Medical Students Associations IFMSA) said that IFMSA was the biggest and oldest students’ organization, with
representation in 75 countries. Apart from encouraging the exchange of students, the
Association supported projects on public health, health education and environmental
awareness. It offered assistance to refugees and orphans, besides assisting in the provision
of books and organizing workshops on medical education. Seminars, workshops and training
programmes were also conducted at national and international levels, to raise awareness
among medical students and to sensitize them in public and reproductive health.
PROF. DR M. JALISI (International Federation of Oto-rhino-laryngological Societies)
said that deafness in children was a major preventable problem in South-East Asia affecting
0.5 per cent of all children. This problem could be addressed using a three-pronged
approach of compulsory registration of all high-risk neonates, mass campaigns aimed at
early detection of the problem and efficient management. He sought WHO’s support in this
context.
DR S.P. AWASTHY (All India Medical Laboratory Technologists Association - AIMLT)
stressed the importance of improving the quality of diagnosis and treatment of diseases.
AIMLT felt that the quality of education in medical laboratory science was of utmost
importance to the national health care system. He sought WHO support in the
standardization of diagnosis and requested the establishment of an Expert Committee on
Laboratory Diagnosis Standardization and Quality Assurance to achieve harmonization
within the field of laboratory diagnostics.
DR PRABHAKAR SAMSON (International Federation of Anti Leprosy Associations)
regretted the absence of any reference to leprosy in the World Health Report 1999.
DR TULSI BASU (Medical Women’s International Association - MWIA) stated that
MWIA, consisting of representation in 74 countries, aimed at affording medical women the
opportunity to consider common problems together, particularly in international health. The
Association also aimed to foster friendship, respect and understanding and to promote the
entry of women into medical and allied sciences throughout the world with a view to making
optimum utilization of their training. Its activities encompassed total health care of
underprivileged women and children, organizing rural health camps, hygiene literacy
programmes, family planning, child welfare and training of junior doctors and paramedicals.
The South East Asian Flame
(SEAAT flame)
I!
for
i
Freedom from Tobacco
•b
freedom from tobacco
WHO South-East Asia Region
Draft Guidelines
1
i
for organizing
Local Events and Celebrations
I
J
1
Table of Contents
!
1. What is this document about?
2
2. Background information
2
3. Organizing the event
5
4. Promoting the event
7
5. Precautions / Recommendations for local events
9
6. Feedback
10
7. Inquiries
10
This document aims to provide an outline on the background issues, objectives and
methodology of organizing the SEAAT Flame campaign at country and local levels.
The main target of the campaign is the population as a whole, with a special focus on the
involvement of a wide audience of policy makers, community activists, youth and women.
Specific details may vary based on the resources available as well as on the nature of the
setting. The general information outlined here is meant to be adapted to meet the needs of
any individual country or location.
2. Background information
'U.
2.1 Why a movement for a tobacco free Region?
The use of tobacco, both in smoking and smokeless forms is the most preventable cause of
disease and death among adults in the world today.
As developed countries become more successful in their tobacco control efforts, tobacco
multinationals are focusing on developing countries including countries of the Region, where
there are few restrictions for these companies to operate. In most of the countries of the Region,
a significant percentage of the population belongs to the adolescent and younger age groups.
The smoking prevalence among women in these countries is still significantly lower than in
developed countries. Therefore the young and the women of developing countries are now
increasingly targeted by the tobacco industry to increase sales, in order to offset decreasing
sales in developed countries, and to pay compensation for victims of tobacco in developed
countries.
Despite control efforts over the years, tobacco consumption is increasing in the Region,
especially among the young, the women and the poor. Therefore, the negative health and
economic impact of tobacco use in the next century will be severe unless effective action is taken
now.
2
2.2 Why a flame?
The SEAAT Flame for Freedom from Tobacco
meant to create an energetic symbol for
stimulating and increasing the momentum of societal action against tobacco.
The flame in many cultures is a symbol of life, youth and victory of good over evil. The SEAAT
Flame symbolizes freedom from dependence on tobacco, and is a salutation to the ability of
Man to rise from the ashes to the aspirational goals.
So far, the anti tobacco movement in the Region has had no logo or an icon to facilitate
recognition and identification. This flame would ideally serve this purpose in the campaign for
a tobacco-free Region.
2.3 What are our aims?
The aims of the SEAAT Flame is to enlighten and awaken policy makers and the public on
issues related to tobacco use, and to initiate and sustain a Region-wide campaign to reduce
tobacco use through the mobilization of youth* and women’s groups, as well as the civil
society. The thrust of the project will be to promote health and well being, and stimulate social
and economic development by reducing tobacco consumption and related harm.
It is envisaged that the Flame will ignite and strengthen a sustained tobacco control campaign
in each country of the Region. Therefore the arrival of the flame and the activities surrounding
the tour of the flame in a country should also be used to launch a sustained campaign on
tobacco control, which should continue, following the departure of the Flame from the country.
2.4 What do we expect to achieve?
There are several outcomes expected. First, it is envisaged that this campaign will sensitize
policy makers on issues related to tobacco and the need for political commitment to enhance
tobacco control at the national level. It is also planned to achieve heightened awareness
among the youth, women’s groups and the general public on issues related to tobacco such
as the health and economic implications, the tactics of the tobacco industry, and effective •
policy measures for tobacco control.
It is anticipated that the campaign will stimulate these groups, communities and civil society to
advocate for new and effective legislation and for implementation and monitoring of existing
legislation and administrative directions on tobacco control. It is also anticipated that the
3
campaign will help to build a cadre of volunteers particularly among the youth in each country
to continue the campaign for a tobacco-free Region.
2.5 Who are we trying to target?
The target is the population as a whole, with special focus on policy-makers, the youth and
women. Involvement of the youth and women is critical for the success of the campaign, as
they are the important targets of marketing strategies of the tobacco industry.
2.6 What messages can be used?
There are several messages that can be conveyed during the campaign. The most
appropriate message or messages should be decided upon by the country, depending on the
extent of the tobacco problem and setting.
Key messages should include the following: tobacco is addictive and it kills, tobacco use
makes people poor, effective policy measures are available to reduce tobacco consumption
and these should be implemented now, the tobacco companies indulge in various activities to
lure children to smoke and delay / stop tobacco control policies.
Messages to highlight the net economic loss suffered by the country due to tobacco and the
environmental consequences of tobacco use, including deforestation can be developed. The
risk of non-smokers and children becoming ill due to environmental tobacco smoke should
also be highlighted.
2.7 What should the country level events be like?
The SEAAT Flame campaign will be launched from New Delhi, India, by Dr. Gro Harlem
Brundtland, the Director-General of WHO in January 2000. The Flame will then pass through
major states, cities and towns of Member Countries of the WHO South East Asia Region,
and end in New Delhi within one year.
At each Member Country of the Region, The SEAAT Flame will be received at the airport and
commence its tour throughout the country. The Flame will be received at predetermined .
locations in the country at predetermined dates and times. The local events should be
organized around the arrival of the Flame to a specific location. It is recommended that each
country develop an outline of activities to be carried out at national and local levels, including
dates, times and people responsible, while the Flame is passing through the country. The
suggested format of .local events is described in section 3.4
4
3.1 Setting up organizing committees
The organizational structure of the SEAAT Flame at county level is proposed to be as follows:
National Co-ordinating Committee
State / Provincial Committees
District Committees
i
Community or Local Committees
The need for and the number of State / Provincial, District and Community / Local committees
in individual countries should be decided upon by the National Co-ordinating Committee.
The ideal organizing committee should reflect a broad diversity of opinions and backgrounds.
The different experiences, networks and competencies that different individuals and
organizations bring to the committee could be applied towards the ultimate goal of promoting
tobacco control. Ideally, local and regional policy makers, government and nongovernmental
organizations, youth and women’s groups, and media personnel should be involved in
organizing the event.
5
3.2 Time and duration
The Flame will travel throughout the Region for a period of one year. The duration that the
campaign will be held in Member Countries will differ according to the population in each
country.
Total weeks in country
Proposed date of Arrival
India (1)’
3
8,h Jan 2000
Bangladesh
8
1st Feb 2000
Nepal
4
1st April 2000
Thailand
4
l-M., 2000
Bhutan
2
1st Jun 2000
Indonesia
10
Inn 2000
15 Jun
India (2)
10
1st Sep 2000
Country
15-NOV2000
Sri Lanka
Maldives
2
1slDec 2000
My.„™r
3
15’ D- 2000.
India (3)
1
7,h Jan 2001
The Flame will visit India three times during the period of the campaign. The final appearance
will be for a week for the conclusion of the Regional campaign.
3.3 Format of local events.
The format of the local event should be decided by the local organizers, depending on local
conditions. Public meetings, exhibitions, youth camps, cultural shows, street drama, musical
events and competitions are some of the events that can be organized to reinforce the
messages. Appropriate entertainment will make the event more attractive and celebratory.
Speeches are important, but the number of speakers should be kept to a minimum and
decided upon earlier. The duration of the speeches should be short to ensure interest of the
participants and the subject area to be covered by each speaker must be specified in
advance to prevent repetition.
6
Distribution or sale of food, drinks and memorabilia during the event should be given
consideration. Setting up
information stands or exhibitions on various issues related to
tobacco will reinforce the messages being conveyed. Government and nongovernmental
organizations working on issues related to tobacco control will be able to help in this regard.
3.4 Setting
The local events should be held in a location with good infrastructure facilities, to enable
public meetings, street drama, exhibitions and other activities to be carried out smoothly. The
selected location should have easy access to public transport and parking. The route of any
walks if organized, should be mapped out on a safe and flat route. A shaded area would be
ideal.
3.5 Linking the celebrations to local traditions
Every effort should be made to reconcile the aims of the walk event with local traditions. The
event could also be held in conjunction with local celebrations or commemorations. The World
No Tobacco Day (31st March) or Independence days of each country could be linked to the
campaign.
wlllBroniotirig the event
1
4.1 Promoting a slogan and a logo.
Promotion of the SEAAT Flame campaign should commence well in advance of the arrival of
the Flame to the country. This should be promoted as a community event. It should be made
clear that tobacco control is the responsibility of all citizens and professions, not only of health
workers. There should be emphasis on the fact that this is an anti-tobacco campaign, and not
an anti-tobacco user campaign. The support of the tobacco users should be actively sought to
make the event a success. Such an approach will also help to initiate attitudinal changes
regarding tobacco use among tobacco users.
7
I
/
A
ftie:e:dcjm from tobacco
WHO South-East Asia Ftagion
The slogan for the SEAAT Flame campaign is “Freedom from Tobacco”. This slogan is
appropriate for non-tobacco users as well as for current users.
A logo has been designed to represent the concept of the SEAAT Flame. It consists of an
image of a flame on a torch resembling a gymnast with out-stretched arms against the
backdrop of the sun. Bright yellow, orange and red used in this logo are the colours of youth
and energy. This icon is versatile, and can be easily adapted to various modes of print and
reproduction.
4.2 Use of media
The event should involve media and public relations professionals and sponsors from non
governmental and private organizations. The focus should be on raising the awareness of the
general public through the use of various media: newspapers, posters, radio and television
announcements etc.
Community
groups,
nongovernmental
organizations,
local
government
and
media
organizations need to be contacted to promote the event and to disseminate information.
4.3 Potential sponsors
Corporate sponsorship and government assistance should be sought to supplement funding.
In exchange for exclusive advertising rights, for example, a company might be persuaded to
8
. support local events even financially. Alternatively, donations of food, drinks, T-shirts and
other items might be solicited for the event.
In keeping with the inclusive theme of the event, it is suggested that the celebration be kept
entirely non partisan and politically neutral. Organizers may choose either to discourage direct
participation by political action groups or to include a broad range of political ideologies
among the organizers and participants of the event.
6P
a
9
9
5.1 Permission for local events
Permission to conduct such an event should be sought from the concerned authorities well in
advance, before any organizational activities take place. It is recommended that such
permission is obtained in writing to prevent any misunderstandings.
5.2 Rain date
Be sure to have a clear rain policy. Either set an alternative date in the event of rain on the
scheduled date of the local events, or make it clear that the events will go ahead, come rain
or shine.
5.3 Advertising
Be sure to check local newspapers for advertisement submission deadlines if advertising is
used.
5.4 Police
Be sure to obtain cooperation of the police to control traffic. Local police departments usually
allocate a number of marshals based on the number of people you expect to attend.
5.5 Medical precautions
Have a sufficient number of medical or paramedical personnel on hand if a large crowd in
expected. Local hospitals or voluntary medical organizations should be contacted in this
regard.
5.6 Alternative power and water supplies
Discuss the issue of alternative electricity and water supply with local authorities and
sponsors to ensure smooth functioning of local events.
9
tH
The expectation is that this should not be a single event. Rather, the SEAAT Flame campaign
is envisaged to stimulate and sustain tobacco control campaigns in each country. Local
events should also give
impetus to other cities and towns to have similar events and
campaigns. Therefore feed back is extremely important to improve any such future events.
Have a phone number and an address for people to contact in case they wish to make
suggestions or inquiries before, during and after the events.
Keep WHO/SEARO up-to-date about your progress, concerns and questions.
Please send your correspondence to:
Mrs Martha R. Osei
Regional Advisor for Health Promotion and Education
World Health Organization
Regional Office for South-East Asia
World Health House
Mahatma Gandhi Marg
New Delhi 110 002
India
Tel: 0091-11-3317804 to 3317823
Fax: 0091-11-3318607
E mail: <oseim@whosea.org>
10
NEXT DECADE CRUCIAL FOR TOBACCO CONTROI
3.'0
http://www.worldbank.org/html/extdr/extme/1439.htr
THE WORLD BANK GROUP
A World f
of Poverty
NOME
PRESS RELEASE
News Release No. 98/1439
Contacts: Gina Cicatelli (202) 458-4166
Fax: (202)522-2616
NEXT DECADE CRUCIAL FOR TOBACCO CONTROL
World Bank Says that Tobacco is Harmful to Health and
Economies
BEIJING, August 25, 1997 — Using tobacco harms people's health and causes economic
loss-therefore, governments must make a priority of tighter tobacco controls, according to World Bank
experts at the 10th World Conference on Tobacco or Health in China. The poor suffer
disproportionately as a result of tobacco use, the World Bank said.
'Tobacco use causes profound health and economic losses. Controlling it should he efficient and
\
cost-effective and governments must lead those controls by aggressively adopting fiscal and regulatory
policies." said Dr. Prabhat Jha, Health Specialist at the World Bank.
I
Tobacco use is rising in many developing countries. Tobacco-related deaths are expected to increase to
10 million per year in less than three decades, with 70 percent occurring in developing countries-a total
which will exceed all fatalities from HIV infection, malaria, tuberculosis, and maternal complications
combined.
In addition to its damage to health, tobacco use causes considerable economic loss through rising
health costs, and loss of productivity. The World Bank's prelimimary estimate for tobacco
consumption in 1990 was US$200 billion per year net economic loss. The Bank argues that
governments and ‘’evelopment agencies should focus on reducing demand for iobai.« o, and hmitmg its
supply, through the following measures:
•
•
•
•
Make tobacco control a public policy priority;
Increase analysis of causes, consequences, and costs of tobacco use;
Focus on effective and cost-effective restrictions; and
Develop global and regional taxation and regulatory measures.
The World Bank, since 1992, has formally adopted a policy of not lending for tobacco production,
processing, or marketing, as well as encouraging greater tobacco controls.
KEY POLICY RECOMMENDATIONS BY THE WORLD BANK TO CLIENT
GOVERNMENTS
• Adopt significant tax and price increases-with adjustment for inflation;
• Implement complete bans on tobacco advertising and promotion of tobacco goods,
trademarks, or logos;
• Disseminate clear information on health risks of tobacco use; and
• Research the causes, consequences, and costs of tobacco use.
6/9/99 11:59 AM
NpXT DECADE CRUCIAL FOR TOBACCO CONTROI
H 2 of 2
S6ARCH
ftEBSACK
http://www.worldbank.org/html/extdr/extme/1439.htr
■
SITE MAP
SHOWCASE
6/9/99 11:59 AM
rraincworK couvcnuon on xuvaccu
3-H
Control (FCTC) - A Primer
I
The Framework Convention will
establish the legal parameters and
structures of the public health tool. It’s a
little like laying the foundation of a
building.
The spectacular rise and spread of tobacco
consumption around the world is a challenge
and an.opportunity for the World Health
Organization. The challenge comes in seeking
global solutions for a problem that cuts across
national boundaries, cultures, societies and
socio- economic strata. The unique and
massive public health impact of tobacco
provides the WHO an opportunity to propose
to the world a first comprehensive response to
deal with the silent epidemic as the tobacco
menace has often been called. The Tobacco
Free Initiative (TFI) has begun preliminary
work in this direction.
The Protocols will be separate
agreements that will make up the
substantive part of the agreement building on the foundation.
2. When will it be completed?
The accelerated FCTC work plan, which was
endorsed by the WHO Cabinet in September
1998, foresees the adoption of the Framework
Convention and possible related protocols by
the World Health Assembly no later than May
2003. Each negotiating process is unique and
has its own momentum. The FCTC can be
completed earlier if WHO’s Member States so
decide. Much depends on
political will and a sustained commitment to
the cause of public health. One option would
be to negotiate one or more protocols
simultaneously with the Framework
Convention.
The FCTC’s benefits to countries are many.
The most significant one is that with the
Convention as a pathfinder and coordination
vehicle, national public health policies,
tailored around national needs, can be
advanced without the risk of being undone by
transnational phenomena (e.g. smuggling).
While framework conventions obligate States
to cooperate in key areas, the process also
serves to forge important links between
countries and other potential partners.
Countries can participate in the central
framework while still deferring a decision on
whether to participate in protocols.
In one case, for example, three Protocols were
negotiated along with the main body of the
Framework Convention'.
3. How will the FCTC help international
tobacco control?
I. The FCTC and related protocols will
improve transnational tobacco control
and cooperation through the following
Framework Convention on Tobacco
Control (FCTC) - A Primer
1. What is the FCTC?
The Framework Convention on Tobacco
Control (FCTC) will be an international legal
instrument that will circumscribe the global
spread of tobacco and tobacco products. This
is the first time that the WHO has activated
Article 19 of its constitution, which allows the
Organization to develop and adopt such a
Convention. In fact, the FCTC negotiations
and the adoption of the Convention should
be seen as a process and a product in
service of public health.
?
This instrument will be developed by WHO’s
191 Member States so that their concerns are
adequately reflected throughout the process.
In fact, the framework convention/protocol
approach will allow Member States to proceed
with the process of crafting this piece of
international legislation in incremental stages:
avenues:
The guiding principles of the Convention
could encompass both national and
transnational measures making it clear
that: tobacco is an important contributor
to inequity in health in all societies; as a
result of the addictive nature and health
damage associated with tobacco use it
must be considered as a harmful
commodity; the public has a right to be
fully informed about the health
consequences of using tobacco products;
1 Reference is made to the "Convention on the
prohibition and restrictions on the use of certain
conventional weapons which may be deemed to be
excessively injurious or to have indiscriminate
effects' (1980).
2
and the health sector has a leading
responsibility to combat the tobacco
epidemic, but success cannot be
achieved without the full contribution of
all sectors of society.
members of civil society in support of
tobacco control.
In the run-up to the adoption of the FCTC, the
WHO and its Regional Offices will work with
NGO’s, media and civil society in countries to
focus on tobacco in all its dimensions.
Under the Convention, State Parties
would take appropriate measures to fulfil,
through coordinated actions, the general
objectives which they had jointly agreed
to. In this respect, the FCTC could
include the following general objectives:
protecting children and adolescents from
exposure to and use of tobacco products
and their promotion; preventing and
treating tobacco dependence; promoting
smoke-free environments; promoting
healthy tobacco-free economies,
especially stopping smuggling;
strengthening women’s leadership role in
tobacco control; enhancing the capacity
of all Member States in tobacco control
and improving knowledge and exchange
of information at national and
international levels; and protecting
vulnerable communities, including
indigenous peoples.
4. What is the difference between a treaty, a
convention, a protocol and a resolution?
• A treaty is an international legal
agreement concluded between States in
written form, and governed by
international law;
• A convention (and also a framework
convention) is a different name for a treaty;
• A protocol is also a form of treaty. It
typically supplements, clarifies, amends or
qualifies an existing international
agreement, for example, a framework
convention;
• A resolution is an expression of common
interest of numerous states in specific areas
of international cooperation.
5. Which of the above is legally binding?
Treaties are legally binding. The framework
convention usually entails more general or
limited obligations, while the protocols
involve more specific legal obligations.
The protocols could include specific
obligations to address inter alia-, prices,
smuggling, tax-free tobacco products,
advertising/sponsorships, Internet
advertising/trade, testing methods,
package design/labeling, information
sharing, and agricultural diversification.
A resolution is non-binding and does not
normally entail any substantive commitments
of a legal nature.
Unless national and transnational dimensions
of tobacco control are addressed in tandem,
even the best comprehensive national control
programs can be undone. The national and
global thrusts of the Convention, by the way,
are interdependent.
II.
6. In this case wouldn’t a resolution suffice?
A resolution is not sufficient to deal
effectively with the public health threats
associated with the tobacco trade, its
marketing, and use. Over the past 25 years,
the World Health Assembly has adopted 16
resolutions on several aspects of tobacco
control with varying degrees of success.
Some Member States have sharpened these
resolutions domestically giving them more
focus and bite. This piece-meal approach,
however, is too informal to be of any major
consequence, especially for tobacco control
where the international dimension of the
problem has a direct bearing on how the issue
is addressed domestically. However,
resolutions adopted in other international fora
The process of developing and adopting
the FCTC and related protocols will also
help to: mobilize national and global
technical and financial support for
tobacco control; raise awareness among
several ministries likely to come into the
loop of global tobacco control, as well as
various sectors of society directly
concerned with the public health aspects
of tobacco; strengthen national legislation
and action; and mobilize NGOs and other
3
will undoubtedly support and act as a catalyst
for the FCTC process.
in this process is to provide technical support
and advice to Member States in the
negotiation of the FCTC and related protocols.
The Framework Convention is about tobacco
control in the long run. The FCTC’s principal
advantage is that it will allow the WHO and
its extended family - which includes
individual countries and individuals in
countries - to reap the public health benefits
resulting from the control of tobacco and its
spread through society. This is a legal
instrument in service of health.
9. Why have so many committees and
groups? Why not go for a single negotiating
mandate instead of re-visiting the WHA so
many times?
A certain degree of flexibility in the approach
exists. For instance, an Intergovernmental
Conference would not necessarily be required
for the adoption of the FCTC and possible
related protocols, as they could be adopted
directly by a two-thirds majority in the World
Health Assembly under Article 19. Moreover,
it is preferable that the World Health
Assembly adopts a single resolution on how it
plans to proceed with negotiations. Towards
this end, the World Health Assembly could
authorize the establishment of an
Intergovernmental Negotiating Committee,
under the proposed resolution now before the
Executive Board. This would be more
efficient than returning to the WHA again at a
later date.
7. What happened to the process started in
1996? Wasn’t there a work plan then?
In May 1996, the World Health Assembly
adopted WHA Res. 49.17 calling upon the
Director-General of WHO “to initiate the
development of a Framework Convention in
accordance with Article 19 of the WHO
Constitution.” This was the first time the
WHO was activating its constitutional
mandate (Article 19) to develop a convention.
There were no precedents for developing a
detailed work plan. Between 1996-1998 some
preparatory technical work was undertaken,
but no detailed work plan was agreed to. As
part of that work, a preliminary timetable was
circulated during the 51st World Health
Assembly in May 1998. The Tobacco Free
Initiative took the relevant parts of that initial
process into consideration before developing
this detailed work plan which reflects the
political and technical requirements for
negotiating the FCTC.
10. Who is going to pay for the FCTC?
The budget for the FCTC will, initially, need
to be financed through extra-budgetary
funding. These costs will include WHO
technical support, support
for intergovernmental technical and
negotiation meetings, and support for the
establishment of FCTC national commissions
to provide support for the process within
countries. In the medium to long-term regular
budget funds will be required to ensure
sustained implementation.
8. The WHO already has a mandate to
commence negotiations. Why are you
seeking it again?
WHA Res. 49.17 gives the Director-General a
mandate to start work on developing a
Framework Convention in accordance with
Article 19, but DOES NOT provide a
mandate to the Director-General to commence
negotiations. The FCTC negotiation is a
prerogative of sovereign States, and requires
the establishment of a formal negotiating
body. Only the World Health Assembly has
the legal authority to launch the negotiating
process. The accelerated work plan and the
draft resolution proposed by the Secretariat
suggests that an Intergovernmental
Negotiating Committee be established by the
Assembly to proceed with formal
negotiations. The role of the WHO Secretariat
In particular, developing countries will require
financial and technical assistance to
participate in the process of formulating the
FCTC. In this regard, the recent technical
consultation in Vancouver recommended that
WHO establish a separate Trust Fund for this
purpose.
Resources will also be required during the
implementation phase. Funds will be
necessary to help countries build capacity and
participate in global and national tobacco
control activities. In this respect, provision
should be made in the FCTC for the
establishment of a Multilateral Trust Fund,
4
services in the economy. Therefore, falling
employment in the tobacco industry will be
offset by increases in employment in other
industries. However, in the short-term, for
countries which rely heavily on tobacco
exports (i.e. the economy is a net exporter of
tobacco), economic/ agricultural
diversification will likely entail employment
losses.
with contributions from governments,
international agencies, and private sources.
11. Will resources from on-going tobacco
control be diverted to the FCTC process?
New extra-budgetary funds will need to be
committed to the FCTC process, but no
previously allocated funds for tobacco control
will be diverted to support the FCTC process.
Support to the FCTC should be seen as an
integral part of supporting national and global
tobacco control. In reality, the successful
adoption of the FCTC will likely result in a
marked increase in financial resources for
tobacco control both within countries and at
the international level. The FCTC, when
adopted, will ensure that tobacco control is
given a higher political profile. The adoption
of the FCTC represents a barometer of success
or failure in placing tobacco control front and
centre on the global stage.
The FCTC takes a long-term view of
agricultural diversification. The framework
protocol approach provides for an
evolutionary approach to developing an
international legal regime for tobacco control,
and thus all issues will not need to be
addressed at the same time. Further, the need
for a multilateral fund to assist those countries
which will bear the highest adjustment cost
needs to be established. The FCTC will
probably be the first instrument seeking global
support for tobacco farmers.
The environmental movement has been
successful in having numerous multilateral
binding agreements adopted at the
international level, and as part of some of
these agreements, for example the 1987
Montreal Protocol on Substances that Deplete
the Ozone Layer, significant financial
resources have been made available to assist
developing countries. Similarly, the FCTC
could facilitate global cooperative actions,
including the flow of additional financial
resources.
Also, it is worth noting that the current 1.1
billion smokers in the world are predicted to
rise to 1.64 billion by 2025, mainly due to
population increases in developing countries.
Therefore, tobacco growing countries are
extremely unlikely to suffer economically
from any tobacco control measures such as the
FCTC.
13. Which ministries are expected to be
involved in the negotiations?
In addition to the leading role of the Ministries
of Health, Ministries of Foreign Affairs
typically take a lead role in the negotiation of
conventions/treaties. Ministries of Finance,
Environment, Labour, Justice, Foreign Trade,
Education and Agriculture will also be
expected to come into the ambit of the
negotiations at some point.
12. What will happen to economies that
depend on tobacco?
The widely held perception that tobacco
control will lead to'loss of revenues is really a
perception! In reality, the numbers are
heavily in favor of moving away from tobacco
cultivation. Recent economic analyses, for
example World Bank data to be published this
year, as well as the publication, “The
Economics of Tobacco Control: Towards an
optimal policy mix’’, show that the social and
health costs of tobacco far outweigh the direct
economic benefits that may be possible
because of tobacco cultivation.
14. Do internationally binding
conventions/treaties lead to action and
tangible results?
Adopting an international agreement can make
a significant difference. For example:
9
The tobacco industry relies on the argument
that there are no real crop or other substitution
options. It is reasonable to assume that
consumers who stop smoking will reallocate
their tobacco expenditure to other goods and
5
Production and consumption of
substances that deplete the stratospheric
ozone layer have declined dramatically
over the last decade, as a result of the
Montreal Ozone Protocol.
1
tobacco control, particularly if extensive
negotiation of the Convention is required.
The General Agreement on Tariffs and
Trade has brought down trade barriers
and promoted the expansion of
international trade.
?
Complex technical standards on tobacco
control should be established and monitored
by WHO, the primary specialized agency in
public health. In WHA 49.17 Member States
recognized the unique capacity of WHO to
serve as a platform for the adoption of the
FCTC by calling upon the Organization to
initiate the development of the Convention.
Arms control agreements have limited
nuclear weapons proliferation and have
led to a substantial reduction in the
arsenals of the nuclear powers.
9
Can international agreements affect the
behaviour of States? In some cases,
international agreements establish meaningful
enforcement mechanisms, such as the World
Trade Organization’s dispute settlement
system. But even in the absence of such
mechanisms, an international agreement can.
However, in so far as the ultimate goal of
global tobacco control may require the
regulation of areas falling within the mandate
of other United Nations’ Bodies establishment
of a joint negotiating mechanism, especially
with regard to possible specialized protocols,
could be considered as an option.
establish review mechanisms that focus
pressure on States by holding them up to
public scrutiny;
9
9
articulate legal rules that may be
enforceable in domestic courts;
9
provide supporters within national
governments with additional leverage to
pursue the treaty’s goals.
16. What linkages will the work on the
FCTC have with other regional
/international agreements, which could
have added value for the FCTC?
Under the WHO/UNICEF project, “Building
alliances and taking action to create a
generation of tobacco-free children and youth,
supported by the United Nations Foundation, a
review of the Convention on the Rights of the
Child with respect to tobacco control, is
currently being conducted. Also, with respect
to TFI’s work on strengthening the role of
women in global tobacco control, possible
links between the FCTC and the United
Nation’s Convention on the Elimination of all
Forms of Discrimination Against Women
(CEDAW), will be considered. Links between
the FCTC and other international treaties
addressing issues such as smuggling will also
be examined. Furthermore, all efforts will be
made to build on proposed and existing
regional tobacco control agreements.
Thus, while treaties rarely cause a state to
immediately reverse its behaviour, they can
produce significant shifts in behaviour, both
because they change a State’s calculation of
costs and benefits, and because most states
feel that they ought to comply with their
promises.
15. Why should the FCTC be developed and
negotiated under the auspices of the World
Health Organization, rather than, for
example, under the umbrella of the United
Nations?
The World Health Organization is the only
international multilateral organization that
brings together the technical and public health
expertise necessary to serve as a platform for
the negotiation and effective implementation
of the Framework Convention on Tobacco
Control. Although the United Nations also
has the legal authority to sponsor the creation
of international instruments on tobacco
control, the UN has neither the specialized
technical expertise nor, perhaps, the time to
engage in negotiating complex standards on
6
!
I
I
3-' 'i
1
?
5
Tobacco Sifuai on
in
Soufh-Gasf Hsia Region
World Health Organization
Regional Office for South-East Asia
New Delhi
Tobacco Or Health
The situation in South-East Asia Region
"EVERY TEN SECONDS another person dies as a result of tobacco use. Tobacco
products are estimated to have caused around 3 million deaths a year in the early
1990s. The death toll is steadily increasing. Unless current smoking trends are
reversed, this figure is expected to rise to 10 million by the 2020s or 2030s.
Unfortunately, 70% of those deaths would occur in developing countries (WHO.
Tobacco Alert 1996)."
This has been the basis of the clarion call to action by WHO since the 1970s.
Global status:
The shift in
tobacco use
from developed
to developing
countries
Tobacco or Health
T
THE
STRINGENT tobacco
control efforts and intensified
advocacy and public educa
tion by the developed world
are yielding beneficial results
in decreasing tobacco use. The
shift in tobacco use from
developed
to
developing
countries has been gradual but
steady. Between 1970-72 to
1990-92, cigarette consump
tion increased in some regions
and decreased in others. For
example, over this 20-year
period
adult consumption
remained the same in the
European Region, decreased
in the American Region and
increased in all other regions,
most rapidly in the Western
Pacific Region followed by
South-East Asia.
Cigarette consumption has
decreased
in
developed
countries since 1980-82 but
this decrease has been counter
balanced by a comparable
increase (1.4% per year) in
developing countries. Further,
while in the early 1970s,
average cigarette consumption
per adult was 3.3 times higher
in developed countries than in
developing countries, by the
early 1990s, this ratio had
decreased to 1.8.
WHO estimates that if this
trend continues, per adult
consumption in developing
countries will exceed that of
developed countries shortly
after the turn of the century.
Already, 800 million of the
world's estimated 1100 million
smokers live in developing
countries. It is estimated that by
2020, the transfer of the
tobacco epidemic from rich to
poor countries will be well
advanced with only about 15%
of the world's smokers living in
rich countries. The bulk of 75%
would
be
in
developing
countries.
Of the estimated 10 million
deaths, 7 million will be in the
developing world including
countries of the South-East Asia
Region. By the 2020s, tobacco
will cause more deaths world
wide than HIV/AIDS, tuber
culosis,
maternal
mortality,
motor vehicle accidents, suicide
and homicide combined. For
the countries of the Region,
these are alarming facts.
Page 1
T obacco
control
THE GLOBAL public health community through the World
Health Assembly has expressed increasing concern about the
increasing trends in tobacco use and its health implications.
From 1970 to 1995, the World Health Assembly adopted 14
resolutions, all unanimously, in favour of tobacco control.
Several of the resolutions called for comprehensive tobacco
control programmes and policies. In particular, a resolution
entitled Tobacco or Health, adopted in 1986 (WHA 39.14),
urged Member countries to consider a comprehensive
national tobacco control strategy covering the following nine
elements:
O Measures to ensure that
include the statement
non-smokers
receive
that tobacco is addictive,
effective protection, to
on cigarette packets, and
which they are entitled,
containers of all types of
from involuntary expo
tobacco products.
sure to tobacco smoke, O The establishment of
in
enclosed
public
programmes of education
places, restaurants, trans
and public information
on tobacco and health
port, and places of work
and entertainment.
issues, including smoking
cessa-tion
programmes
O Measures to promote
with active involvement
abstention from the use
of tobacco so as to
of the health professions
protect children and
and the media.
in
young
people
from O Monitoring trends
smoking and other forms
becoming addicted.
of tobacco use, tobaccoi=> Measures to ensure that a
good example is set in all
related
diseases
and
effectiveness of national
health-related
premises
smoking control action.
and
by
all
health
O The promotion of viable
personnel.
O Measures leading to the
economic alternatives to
tobacco
production,
progressive elimination of
trade and taxation.
those
socio-economic,
The establishment of a
behavioural and other
national focal point to
incentives which main
stimulate, support, and
tain and promote the use
coordinate all the above
of tobacco.
activities. •
Q Prominent
health
warnings, which might
South-East Asia where do
we stand?
THE SITUATION of tobacco use in the Region is as complex
as it is intriguing. The tobacco problem is very different from
the rest of the world.
The consumption of tobacco in both its smoking and
smokeless forms such as bidis, kreteks, hookah, pan, pan
masala and gutka, defy standard parameters of measurement.
Per capita consumption of cigarettes or incidence of lung
cancer do not adequately reflect the situation in the Region.
Consequently, the tobacco problem usually gets underplayed.
Page 2
Tobacco or Health
The facts
Eight of the ten Member Countries Bangladesh, DPR Korea, India, Indonesia,
Myanmar, Nepal, Sri Lanka and Thailand produce tobacco in commercial quantities
totalling over 1.03 million tons (1994).
Even in countries such as Bhutan and
Maldives which do not produce tobacco,
there is no dearth of tobacco products.
O’ The Region produces and consumes the
greatest variety of tobacco products cigarettes, bidis, kreteks, keeyos, cigars,
cheroots, chutta, hookahs, pan, pan
masala, gutka, gundi, mishri, gudhaku,
betelquid, etc. These products are freely
accessible.
I®* About 70% of the Region's production of
tobacco totalling millions of metric tons is
consumed locally. This is in addition to
huge
quantities
of
imported,
unmanufactured tobacco and cigarettes.
US’ Some of the tobacco products in the
Region contain the highest levels of
nicotine and tar recorded worldwide,
ranging from 18-58 mg for tar and 0.9-2
mg for nicotine. In Europe, the permissible
level of tar is less than 12 mg.
Two countries are ranked 3rd and 7th
respectively among 25 leading countries
for apparent use of unmanufactured
tobacco.
i®’ Current tobacco consumption rates range
between 55-80% and 3-71% among adult
men and women respectively. These
percentages translate into millions of
tobacco users considering the huge
population size of the Region.
igf There has been a steady increase in
tobacco
consumption
rates
among
children, women and the poorer sections
of society in the Region over the years.
The Region records some of the highest
prevalence rates of 33% among children,
71% for women and 80% among rickshaw
pullers.
BST’
Tobacco or Health
css3 The
projected
per
capita
adult
consumption in the Region is 2.075
against the global figure of 1.86.
bs3 The Region has had the second highest
annual growth rate of 1.8% in per capita
(adult) cigarette consumption among the
six WHO regions for the last two decades.
K33
As many as 5,000 children get addicted to
tobacco every year and it is estimated that
over 4 million children below 15 years are
tobacco users in one country of the Region.
The effects of tobacco-related diseases are
already emerging as major public health
problems in some countries of the Region.
Oral cancer, chronic obstructive lung
disease and ischaemic heart diseases are
major causes of mortality in some
countries of the Region. Among women
who use tobacco, spontaneous abortion
during pregnancy is documented as a
problem in some countries.
D®’
The Region records one of the world's
highest rates in tobacco-related oral cancer
constituting 33% of all cancers in one
country.
irr Annual tobacco deaths range between
57,000 and 630,000 in some countries.
US’
It is projected that by 2020, about 14.5% of
all deaths in some countries in the Region
could be attributable to tobacco use.
With a gestation period of 20-30 years,
tobacco-related problems are projected to
be a major killer in the Region by the
2020s-2030s.
The success of poverty alleviation
programmes in some countries is being
eroded as poor beneficiaries spend as
much as 40% of their income on tobacco
products.
us" The total economic loss attributed to
tobacco use in some countries is very high,
registering as much as US$ 10,085 million
in one country in 1990.
Page 3
What has been
done so far?
SIGNIFICANT STEPS have been taken by almost all countries in
the Region towards tobacco control.
In most countries health warnings are required on cigarette
packets and advertisement of cigarettes are banned on the
electronic media.
Sale of cigarettes to minors is banned in some countries, as is
smoking in public places. Increase in taxes on cigarettes has
decreased access while providing revenue for health promotion
interventions in two countries.
A ban on in-flight smoking on both local and international
flights has been initiated in many countries of the Region.
Promotion of tobacco products by gifts, samples and exchanges
is prohibited in some countries. In two countries, crop substitution
has been tried while islands and districts have been declared
tobacco-free.
Public education and advocacy for tobacco control has been
an important prevention programme in all countries.
Community-based tobacco prevention programmes have been
undertaken in most countries. Smoking in public places including
schools, hospitals, cinema houses etc. have been banned in most
countries.
Some
soui-searcning
questions
IT IS CLEAR THAT current control efforts need to be intensified
and recognized as a priority for national, social, health and
economic development. The dangers of increasing tobacco use
are also obvious. With the tightening control measures being
undertaken in America and Europe and very soon in China, the
countries of the South-East Asia Region face a substantial risk of
being the dumping ground of tobacco industries and their
products. Aggressive tobacco advertisement glamourizing and
promoting tobacco use has contributed significantly to the
increase in tobacco use. The great accessibility to non-taxed
tobacco products such as bidi, pan and pan masala is also a cause
for concern.
What would happen if control efforts are not intensified now?
O Millions of children would be addicted to tobacco and
eventually die prematurely of tobacco-related diseases.
O Tobacco related health problems among adult smokers would
quickly overtake those of communicable diseases. Millions of
cases of cancers, heart diseases and respiratory tract
infections would be reported.
O The revenue now realized from tobacco and much more
from the health budget would be used to treat and manage
tobacco-related diseases.
Page 4
Tobacco or Health
But the question is:
O Would our health systems be able to cope with the demand
for health care for tobacco-related problems?
O Can we afford the millions in hard currency which could go
into treating and managing tobacco-related problems?
i=> Can we afford to lose millions of youth, the cream of our
human resources, prematurely?
<=> How would families cope with the heavy social, financial and
psychological burden which come with the premature death
of the breadwinner of the family?
There should be answers to these questions! The answer lies in
sustained and collective control efforts at all levels within and
between Member Countries.
What can
the health
ministries
do?
THE LEAD ROLE of Health Ministries in the battle against tobacco
use cannot be over-emphasized in facilitating sustained tobacco
control efforts.
O National comprehensive strategies incorporating the nine
elements enshrined in WHA 39.14 need to be articulated
clearly in the context of national development policies.
O Systematic and sustained advocacy to put tobacco control on
the agenda of national development is an urgent pre
requisite.
i=> Increase in tobacco taxes to decrease availability has been
found to be one of the effective ways to reduce access and
needs to be promoted vigorously.
i=> Intensified education programmes for vulnerable groups such
as children, women and the poor sections of the population
should be given priority.
O Integration of tobacco control activities into primary health
care and other development programmes should be the
ultimate goal of health ministers and their partners.
(4> A specific budget allocation for tobacco control should be
seriously considered.
<=> Initiation of tobacco cessation programmes for those addicted
to tobacco would help reduce the burden of tobacco-related
diseases.
O Banning tobacco promotion and advertisement in various
forms must become a critical tobacco control weapon.
The challenge is obviously daunting but definitely not unsurmountable. With
focused commitment and determination, countries of the South-East Asia
Region can be tobacco-free. The Region can provide the lead in working
towards a tobacco-free world.
Tobacco or Health
Page 5
J
V
t ^1948
®1998
WORLD HEALTH ORGANIZATION
HEALTH FOR ALL: ALL FOR HEALTH
3d 3
t
WORLD
HEALTH
REGIONAL OFFICE FOR
SOUTH-EAST ASIA
ORGANIZATION
4
R
E
G
I
O
N
A
L
O
M
M
REGIONAL COMMITTEE
SEA/RC52/16
Fifty-second Session
6-9 September 1999
9 September 1999
DRAFT REPORT
OF THE
52nd SESSION OF REGIONAL COMMITTEE
FOR SOUTH-EAST ASIA REGION
E
E
D
O
0
U
M
E
N
TABLE OF CONTENTS
PART I - INTRODUCTION
1
PART II - INAUGURAL SESSION...................................................
Welcome Address by Secretary, Ministry of Health and Family Welfare,
Government of Bangladesh.............................................................
Address by the Regional Director, WHO...........................................
Address by the Director-General, WHO.............................................
Address by State Minister for Health and Family Welfare, Bangladesh..
Address by the Minister of Health and Family Welfare, Bangladesh.....
Inaugural Address by the Prime Minister of Bangladesh......................
Vote of Thanks................................................................................
2
PART III - BUSINESS SESSION.....................................................
2
2
3
3
4
4
5
6
OPENING OF THE SESSION (Agenda Item 1)
6
SUB-COMMITTEE ON CREDENTIALS (Agenda item 2)
6
ELECTION OF CHAIRMAN AND VICE-CHAIRMAN (Agenda item 3)
6
ADOPTION OF AGENDA (Agenda item 4) (document SEA/RC52/1)
6
7
ADDRESS BY THE DIRECTOR-GENERAL, WHO (Agenda item 6)....................
9
Drafting Group on Resolutions..........................................
THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION - REPORT OF THE
REGIONAL DIRECTOR FOR THE PERIOD 1 JULY 1997 - 30 JUNE 1999
(Agenda item 5) (documents SEA/RC52/2, SEA/RC52/lnf. 1 and Inf.2)..............
Address by Chairman, 24th SEA/ACHR......................................................................
Statement by Representatives of Nongovernmental Organizations...............................
.9
15
16
PROGRAMME BUDGET (Agenda item 7).............................................................
17
CONSIDERATION OF THE RECOMMENDATIONS ARISING OUT OF THE
TECHNICAL DISCUSSIONS ON (1) TOBACCO OR HEALTH: ACTIONS
FOR THE 21st CENTURY, AND (2) INTENSIFICATION OF HIV/AIDS
SURVEILLANCE (item 8.1).....................................................................................
Technical Discussions on Tobacco or Health: Actions for the 21st Century.....................
Technical Discussions on Intensification of HIV/AIDS Surveillance................................
SELECTION OF A SUBJECT FOR THE TECHNICAL DISCUSSIONS TO BE
HELD DURING THE 38™ MEETING OF THE CONSULTATIVE COMMITTEE ON
PROGRAMME DEVELOPMENT AND MANAGEMENT (CCPDM) (item 8.2)........
20
20
21
REGIONAL IMPLICATIONS OF THE DECISIONS AND RESOLUTIONS OF
THE FIFTY-SECOND WORLD HEALTH ASSEMBLY AND THE 103rd AND 104™
SESSIONS OF THE EXECUTIVE BOARD AND REVIEW OF THE DRAFT
PROVISIONAL AGENDAS OF THE 105™ SESSION OF THE EXECUTIVE
BOARD AND FIFTY-THIRD WORLD HEALTH ASSEMBLY (Agenda Item 9)......
Part 1........................................................................................................................
Part 2........................................................................................................................
22
22
22
23
Statement by the Representative from the International Federation of Pharmaceutical
Manufacturers
. ...............................................................................................
Statement by the Representative of the World Organization of Family Doctors
ROLL BACK MALARIA (RBM) AND MAINSTREAMING OF ANTI-MALARIA
ACTIVITIES IN HEALTH SECTOR DEVELOPMENT (Item 10)
24
INTERCOUNTRY COOPERATION IN THE SUPPLY OF ESSENTIAL DRUGS
(Agenda item 11) (document SEA/RC52/6)
26
STRENGTHENING POISON CONTROL CENTRES IN THE REGION
(Agenda item 12) (document SEA/RC52/8)
27
UNDP/WORLD BANK/WHO SPECIAL PROGRAMME FOR RESEARCH AND
TRAINING IN TROPICAL RESEARCH DISEASES: JOINT COORDINATING BOARD
(JCB) - ATTENDANCE AT 1999 JCB (Item 13.1)
28
SPECIAL PROGRAMME FOR RESEARCH, DEVELOPMENT AND RESEARCH
TRAINING IN HUMAN REPRODUCTION - REPORT ON THE POLICY AND
COORDINATION COMMITTEE (PCC) SESSION AND NOMINATION OF A
MEMBER TO PCC IN PLACE OF THAILAND WHOSE TERM EXPIRES ON
31 DECEMBER 1999 (item 13.2)
Statement by the Representative of International Planned Parenthood Federation
29
29
WHO ACTION PROGRAME ON ESSENTIAL DRUGS - INFORMATION
PAPER ON THE SESSION OF THE MANAGEMENT ADVISORY
COMMITTEE (MAC) (Item 13.3)
Statement by the Representative of International Organization for Cooperation in Health
TIME AND PLACE OF FORTHCOMING SESSIONS OF THE REGIONAL
COMMITTEE (item 14)
Consideration of Draft Resolutions
24
24
30
30
30
31
SEA/RC52/16
PARTI
INTRODUCTION
THE 52nd SESSION of the WHO Regional Committee for South-East Asia was held in
Dhaka, Bangladesh, from 6 to 9 September 1999. It was attended by representatives of all
the ten Member States of the Region, UN agencies, and nongovernmental organizations
having official relations with WHO as well as observers.
The session was inaugurated by Her Excellency Sheikh Hasina, Hon’ble Prime Minister
of Bangladesh.
The Committee elected Mr M.M. Reza (Bangladesh) as Chairman and Dr Azrul Azwar
(Indonesia) as Vice-Chairman of the session.
The Committee reviewed the report of the Regional Director for the period 1 July 1997
to 30 June 1999, and considered the recommendations arising out of the Technical
Discussions on (1) Tobacco or health: Actions for the 21st century, and (2) Intensification of
HIV/AIDS surveillance, held during the 36th meeting of the Consultative Committee on
Programme Development and Management.
The Director-General of WHO, Dr Gro Harlem Brundtland, addressed the session.
The Committee accepted the confirmation by the Government of India to host its 53rd
session in early September 2000.
A drafting group, consisting of representatives from Bangladesh, Bhutan, India,
Maldives, Nepal and Thailand was formed to draft resolutions for consideration by the
Regional Committee. Ms Sujatha Rao was elected Chairperson of the group. During the
session, the Committee adopted eight resolutions.
SEA/RC52/16
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Part II
INAUGURAL SESSION
Welcome Address by Secretary, Ministry of Health and
Family Welfare, Government of Bangladesh
MR M.M. REZA, Secretary, Ministry of Health and Family Welfare, welcomed the Chief
Guest, Her Excellency Sheikh Hasina, Prime Minister of Bangladesh, and other dignitaries.
He said that the Regional Committee was being held in Bangladesh after a gap of 17 years
during which considerable improvements had taken place in the field of public health. WHO
had provided technical and financial assistance for health development, particularly in the
battle against polio and communicable diseases, such as malaria, tuberculosis and HIV. The
country had recently adopted a sector-wide approach for strengthening health system
structures and functions to help reduce expenditure and improve the health of the people,
particularly the poor. He underscored the importance of ensuring access to drugs and
vaccines as well as the development of new ones to counter major killer diseases. He looked
forward to new directions from the Regional Committee for effectively dealing with health
problems in the country.
Address by the Regional Director, WHO
DR UTON MUCHTAR RAFEI, Regional Director, highlighted the collaborative activities in
Bangladesh and referred to WHO’s support for improving the health of the people,
particularly mothers, children and the poor. WHO had closely worked with the government in
tackling the problem of arsenic contamination of drinking water in the country and ensuring
the safety of blood and blood products, which assumed greater significance in the context of
the emerging problem of HIV/AIDS.
WHO’s partnership with other UN Agencies and nongovernmental organizations, had
resulted in significant gains in the fight against vaccine preventable diseases, including polio,
through synchronized National Immunization Days by several countries of the Region.
Multidrug therapy (MDT) for leprosy control, the DOTS strategy against TB and the use of
impregnated bednets in malaria control were some of the key approaches in WHO
SEA/RC52/16
Page 3
collaborative activities. However, the challenges posed by the growing population, high
maternal mortality and HIV/AIDS, TB, malaria as well as noncommunicable diseases,
avoidable blindness and malnutrition still needed attention. Considering the global economic
scenario, WHO needed to be increasingly effective and efficient, and to prioritize and focus
its support to countries.
Reiterating that health should be treated as central to development, Dr Uton called for
continued collaboration from the Member Countries to enable WHO strengthen its
partnership with development partners to ensure that the benefits of cooperation with WHO
reached people who had been neglected for long.
Address by the Director-General, WHO
DR GRO HARLEM BRUNDTLAND, Director-General, WHO, said that the Organization ’s
decentralized structure was one of its strengths. WHO drew upon the experiences of all
regions and Member Countries. WHO was committed to fight poverty and to promote equity
and access to health benefits for all. Though the South-East Asia Region faced many
challenges, she believed that it had the resources and the ability to overcome them.
Referring to the important role played by WHO in health development in the Region,
Dr Brundtland visualized its continued role as adviser, supporter, catalyst and partner for
ensuring the health of those in greatest need. She sought the cooperation of the Member
Countries in fulfilling WHO’s noble task. She said that as a future member of the United
Nations Development Group, WHO would actively promote coordination and planning with
other UN Agencies.
Address by State Minister for Health and Family Welfare,
Bangladesh
PROFESSOR DR M. AMANULLAH, Minister of State for Health and Family Welfare,
expressed the hope that the outcome of the Regional Committee meeting would help to
develop future health programmes in Bangladesh with intensified WHO collaboration.
Briefly outlining the health programme activities in the country, he said that many of the
benefits from advances in medical technology were yet to reach the third world countries.
Though there had been improvements in health infrastructure development, problems of
SEA/RC52/16
Page 4
poverty, illiteracy, malnutrition and communicable and noncommunicable diseases had yet
to be fully dealt with. Simultaneously, there was the danger posed by emerging killer
diseases, such as HIV/AIDS. He referred to arsenic contamination of drinking water in
Bangladesh and sought WHO’s support in dealing with this problem. He cautioned against
the arms race, particularly the disastrous effects of the use of nuclear weapons. Bangladesh
had embarked on a Health and Population Sector Programme using a comprehensive
sector-wide approach for the provision of health care services. There had been increased
participation of women in social development activities and local government bodies.
Address by the Minister of Health and Family Welfare,
Bangladesh
MR ALHAJ SALAH UDDIN YUSUF, Minister of Health and Family Welfare, thanked WHO
for holding the meeting in Bangladesh and said that he looked forward to benefiting from the
experiences of other Member Countries regarding health development activities. Though
there had been overall improvement in the health situation in the country, continuing
challenges posed by communicable diseases, malnutrition and emerging and re-emerging
diseases needed to be met. At the same time, there had been underutilization of the health
infrastructure, particularly at the Thana level. Provision of basic health services to the entire
population, particularly the underserved, had been a national goal. The Health and
Population Sector Programme, launched in July 1998, was a positive step in this direction.
He identified investment in health and human resources development as critical areas and
sought the support of development partners in this regard. The Global initiatives of the WHO
Director-General, such as Roll Back Malaria, Tobacco Free Initiative and Tuberculosis
Control, were in line with the priorities of Bangladesh. He also referred to the additional
difficulties caused by natural calamities and disasters and underlined the need to strengthen
the country’s capacity and capability to effectively deal with these.
Inaugural Address by the Prime Minister of Bangladesh
HER EXCELLENCY SHEIKH HASINA, Prime Minister of Bangladesh, welcomed the
dignitaries and thanked WHO for holding the Regional Committee session in Bangladesh.
WHO’s assistance in meeting the needs of the developing countries, especially in enhancing
the national capacity building process was much appreciated. She considered health sector
SEA/RC52/16
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reforms as an inevitable process of change leading to wide-ranging improvements in policy
and strategic issues. Countries needed to adjust their policies and strategies according to
the changing needs brought about by the advances in science and technology.
Tracing the history of Bangaldesh, she said that the various pragmatic programmes
initiated by the Father of the Nation, Bangabandhu Sheikh Mujibur Rahman, had helped the
country to achieve notable successes. She specifically referred to enhanced food
production, a reduction in population growth rate and high couple protection rate, increased
life expectancy, and development of the health infrastructure. Of particular importance was
the introduction of the Health and Population Sector Programme (HPSP), a package
encompassing reproductive health, child health, communicable disease control, family
planning and limited curative care at all levels. However, there were formidable health
problems owing to population explosion, poverty, low literacy rate, high maternal mortality
and malnutrition, coupled with a high prevalence of communicable diseases. Re-emerging
communicable diseases, including sexually transmitted diseases and HIV/AIDS, also posed
a grave threat. These issues were being addressed through decentralized administration
and a democratic system.
The Prime Minister highlighted the achievements of her government in reducing the
infant mortality rate through oral rehydration therapy and high immunization coverage. The
recently-launched programme of “Education For All by 2006 AD” would go a long way in
increasing literacy, including adult literacy. Concerned with environmental pollution,
legislation had been enacted regarding rapid deforestation and inappropriate disposal of
industrial waste.
Vote of Thanks
PROFESSOR A.K.M. NURUL ANWAR, Director-General of Health Services, proposed a
vote of thanks.
SEA/RC52/16
Page 6
Part III
BUSINESS SESSION
OPENING OF THE SESSION (Agenda Item 1)
IN THE ABSENCE of the Chairman of the 51st session, Dr U Kyi Soe, Vice-Chairman,
opened the 52nd session of the Regional Committee, which was attended by the Director-
General of WHO, representatives of Member Countries and other participants and
observers.
SUB-COMMITTEE ON CREDENTIALS
(Agenda item 2)
A SUB-COMMITTEE on Credentials, consisting of representatives from Bhutan, DPR Korea
and Nepal was appointed. The Sub-committee met under the chairmanship of Dr Kim Myong
Dok (DPR Korea) and examined the credentials submitted by Bangladesh, Bhutan, DPR
Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka and Thailand. The credentials
were all found to be in order, thus entitling all representatives to take part fully in the work of
the Regional Committee. The report of the Sub-committee (SEA/RC52/15) was approved by
the Regional Committee.
ELECTION OF CHAIRMAN AND VICE-CHAIRMAN
(Agenda item 3)
MR M.M. REZA (Bangladesh) was elected Chairman of the 52nd session of the Regional
Committee. Dr Azrul Azwar (Indonesia) was elected Vice-Chairman.
ADOPTION OF AGENDA (Agenda item 4)
(document SEA/RC52/1)
The Committee adopted the Agenda, as contained in document SEA/RC52/1.
SEA/RC52/16
Page 7
ADDRESS BY THE DIRECTOR-GENERAL, WHO (Agenda item 6)
DR GRO HARLEM BRUNDTLAND said that the Region was capable of meeting the many
challenges it faced. However, the health gains of the past needed to be shared equitably by
all. WHO’s commitment to ensuring better health care to all, particularly the poor, was
relevant to the Region, which comprised one-fourth of the world’s population but had about
40% of the global burden of disease. Improving the effectiveness of WHO was high on her
agenda. The focus on the most important health issues needed to be maintained in a spirit of
partnership. An area of concern was the disproportionately high mortality and the burden of
diseases in the Member Countries of the Region.
The Director-General assessed WHO’s work in the South-East Asia Region based on
four global strategic directions. First, mortality and disability suffered by the poor and
marginalized populations needed to be reduced with the focus on the control of
communicable diseases and conditions that led to increased child and maternal mortality.
Attributing the global progress in polio eradication to the efforts of SEAR countries,
Dr Brundtland said that NIDs were the largest public health campaigns covering millions of
children, made possible through partnerships and with the commitment of health workers
and volunteers. However, improved surveillance and additional rounds of NIDs were
required.
Reiterating WHO’s commitment to fight HIV/AIDS. and its resolve to eventually develop
a vaccine against HIV, Dr Brundtland lauded Thailand’s leadership in spearheading HIV
prevention education campaigns and participation in AIDS vaccine trials. The Stop TB
Initiative was aimed at generating more resources and partnerships for TB control. Urging
Member Countries to achieve 100 per cent coverage with DOTS by the year 2005, she
emphasized the need for increased surveillance for anti-TB drug resistance.
The second strategic direction related to countering potential threats to health resulting
from economic crises, unhealthy environments and risky behaviour. Referring to the arsenic
contamination of drinking water in Bangladesh, she underscored the importance of finding
technical solutions to purify contaminated water as well as to find uncontaminated sources of
water. She called for concerted regional action to support WHO’s global tobacco control
efforts and looked forward to the participation of representatives from the Region in the
SEA/RC52/16
Page 8
working group of the WHO Framework Convention on Tobacco Control in October in
Geneva.
Reforms of health systems, health care financing and ensuring health care coverage for
all formed the third strategic direction. The pre-paid system for health care services placed
less burden on the poor. Member Countries looked to WHO for guidance in handling the
issue of rapid growth of private medical care and channelizing it for achieving public health
goals.
The fourth strategic direction concerned the development agenda and recognizing
health as a key to human development and progress. She said that illness was not only a
result of poverty, but could also be a cause of it. Marked improvements in the health status
and increased life expectancy, in turn, could lead to strong economic growth in the Region.
In view of the budgetary constraints, there was a need to shift resources from low to
high priority areas. A series of efficiency measures had been initiated at the global level to
meet this challenge. Savings were also needed to cover the absence of funding for cost
increases. As a result, the South-East Asia Region should also identify budgetary efficiency
savings for the next biennium in order to focus more sharply on priorities and cover cost
increases. Terming conflict and strife as the worst enemies of health, she said that these
should not negate the benefits of progress achieved through decades of hard work.
•hide
The meeting expressed concern at the proposed budgetary measures, and felt that
savings should be effected by allowing countries and the Regional Office to decide the
specific areas for their achievements within a general target representing a required amount.
Furthermore, the determination of priority areas to which funds would be channelled from
efficiency savings should be left to the countries to decide in consultation with the WHO
Regional Office.
Responding, the Director-General clarified that WHO was a technical agency and not a
funding agency. She was responsible to the World Health Assembly, and while the views of
the Regional Committees provided valuable perspective, Constitutional provisions and the
overriding roles of the Executive Board and the World Health Assembly were to be
acknowledged. Efficiency shifts would not reduce spending at the country level; however,
shifts to priorities were needed. Two-thirds of WHO funds were at country and regional
SEA/RC52/16
Page 9
levels. Waste existed not just at WHO headquarters. The Director-General hoped for country
support in responding to what had been asked of her by the World Health Assembly.
Drafting Group on Resolutions
A DRAFTING GROUP on resolutions, comprising representatives from Bangladesh, Bhutan,
India, Maldives, Nepal and Thailand was constituted. Ms Sujatha Rao (India) was elected
Chairperson of the group.
THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION REPORT OF THE REGIONAL DIRECTOR FOR THE PERIOD
1 JULY 1997 - 30 JUNE 1999 (Agenda item 5)
(documents SEA/RC52/2, SEA/RC52/lnf 1 and Inf. 2)
INTRODUCING his report for the period 1 July 1997 to 30 June 1999, the Regional Director
referred to the change from input-oriented to a product-oriented approach in programme
budgeting and implementation, which had been introduced in 1996. This approach would
ensure that WHO moved steadily towards a result-oriented managerial process.
Recalling the Regional Committee’s decision on pooling of resources for a
supplementary intercountry programme in 1996-1997 and in 1998-1999, the Regional
Director said that problems common to more than one country could be addressed through
enhanced intercountry activities. In this context, he urged Member Countries to focus on
result-oriented intercountry collaborative programmes in response to national technical
needs in support of their health development programmes.
The regional allocation for the biennium 2000-2001 had been reduced by over
$ 3 million compared with 1998-1999 as a result of implementation of resolution, WHA51.31.
The Region now needed to focus its resources in a concentrated manner in order to respond
to the challenges of World Health Assembly resolution, WHA52.20, which called for, among
others, shifting resources out of ineffective areas to higher priorities.
The Regional Director informed the meeting that, in keeping with the Director-General’s
call to make the concept of “one WHO” a reality, the structure of the Regional Office was
being reorganized in line with the clusters in WHO headquarters. The new structure was
SEA/RC52/16
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expected to strengthen opportunities for both intra and interdepartmental teams to jointly
address emerging challenges.
Highlighting WHO’s achievements during the reporting period, Dr Uton said that the
Organization had contributed meaningfully to overall health development in the Member
Countries. Intensified WHO collaborative activities with countries of the Region as well as
WHO initiatives, such as intercountry cooperation for health development, joint planning
initiative, synchronization of National Immunization Days, and coordination of border
meetings had made positive contributions to health development.
WHO had continued to support high-level meetings, such as the Health Ministers
Meeting, the meeting of Health Secretaries and meetings of Medical Parliamentarians, which
had helped to place existing and emerging health development issues high on the political
and development agendas of the countries.
Efforts had been intensified to promote approaches that addressed specific women’s
health issues in the context of women’s lives and their vital role in development. A working
group, constituted in response to the decision of the forty-ninth session of the Regional
Committee, had identified a number of obstacles in the recruitment and retention of women
in professional posts. Specific action on the recommendations of this group was being
formulated. The employment and recruitment of women at the professional level in the
Regional Office had risen from 8-9% in 1993 to 23% at present. A mechanism had been
established to monitor and improve the induction of women to achieve WHO’s long-term
target of gender parity.
★ ★★
***
The Committee lauded WHO’s significant contribution in providing critical support for
eradicating
guinea-worm
disease,
reducing the prevalence of leprosy,
combating
tuberculosis and HIV/AIDS, and near eradication of poliomyelitis. WHO had provided
catalytic support to countries in mobilizing international funding thereby enabling them to
address the health problems and to develop proposals for such funding more effectively. As
the South-East Asia Region comprised a vast geographical area and housed almost a
quarter of the world’s population, it also faced the double burden of disease and burgeoning
populations. The Committee therefore hoped that WHO, at all levels, would recognize these
factors while allocating resources for future collaborative programmes.
SEA/RC52/16
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In order to enable both WHO and Member Countries to assess the impact of WHO
collaborative programmes and their linkage to the overall health and economic development
in Member Countries, the Committee expressed the need for more effective and transparent
monitoring and evaluation systems.
The Committee acknowledged WHO’s significant role in the areas of research and
development of human resources for health, especially through training and fellowships. It
further noted the possibility of conducting in-country fellowships as well as training of health
personnel at national centres of excellence, which would not only be cost-effective but would
also be mutually beneficial for institutions and countries.
Noting that large investments in clinical aspects alone would not be effective in
controlling diseases, the Committee called for further strengthening of public health
administration in Member Countries through enhanced technical support and increased
allocation of budgetary resources.
The Committee appreciated WHO’s assistance in the control of communicable and
noncommunicable diseases. In particular, the support extended to Member Countries had
helped them to overcome the adverse health impacts of the economic crisis and in
strengthening the health system. The need for WHO’s assistance to sustain health
development programmes and in accessing good quality drugs was stressed.
The Committee noted that considerable gains had been made in the past few years in
developing strategies for controlling diseases in the border areas, particularly malaria,
through regular border meetings and enhanced cooperation. Increased border collaboration,
especially at the local level, was recommended.
The Committee noted that conducting rapid assessment among populations with high
risk behaviour, such as injecting drug use, was useful to assess the problem of HIV/AID8.
Such information could help in instituting control measures. At the same time, HIV/AIDS
surveillance, including risk behaviour, was important for planning as well as evaluating the
impact of interventions. In this context, the need for intercountry and interagency
collaboration and exchange of experiences in HIV/AIDS surveillance was stressed.
Remarkable progress had been made in tuberculosis control using the DOTS strategy.
Further rapid expansion of DOTS was expected in the near future so that the goal of nation
wide DOTS coverage of good quality could be achieved in all countries before 2005.
SEA/RC52/16
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The Committee called for according high priority to Integrated Management of
Childhood Illnesses to accelerate reductions in infant and child mortality rates. WHO should
provide enhanced technical expertise and in-service manpower training for achieving this. In
countries where infant mortality rates have declined substantially, WHO should support
programmes to reduce mortality in the neonatal period.
The Committee noted that WHO continued to promote an integrated preventive
approach to address the increasing incidence of cardiovascular and cerebrovascular
diseases, malignancies, metabolic and degenerative disorders and mental illness. Efforts
had been made to increase public awareness and to strengthen programme management
capabilities for PHC personnel.
Technical support was provided to countries in developing basic eye care and ear care
services. Plans were being made to launch Regional Vision 2020 on the lines of Global
Vision 2020, launched by the Director-General early this year.
Member Countries had been supported in operationalizing the regional strategy for
reproductive health, with special focus on reducing maternal mortality. Significant technical
support had been provided to the countries in the areas of mental health, substance abuse,
nutrition, environmental health, essential drugs and traditional medicine through innovative
approaches.
In its fight against tobacco, WHO s focus had been o-« reducing consumption levels and
preventing initiation of tobacco use. A Regional Policy Framework and Plan of Action, which
would be a blueprint for the control of tobacco use, had been developed. The Tobacco Free
Initiative had been included as a priority project in the intercountry programme in 2000-2001.
The Committee was concerned that the shift from component-based approach to
product-oriented approach had caused some difficulty for country programme managers in
the preparation of plans of action. It however, noted that the Regional Office had organized
workshops on programme development and management to orient staff and nationals on the
planning process.
The Committee noted that intensified WHO collaborative activities with countries of the
Region as well as WHO initiatives, such as intercountry cooperation for health development,
SEA/RC52/16
Page 13
joint planning initiative, synchronization of National Immunization Days, and coordination of
border meetings, had made positive contributions to health development.
The Committee stressed the need to reflect in the Regional Director’s biennial report,
important policy issues regarding the improvement of efficiency in WHO as well as problems
and constraints faced by WHO in collaborating with the Member States. It noted that a
working group had been established to study the effectiveness of WHO collaborative
programmes in the countries and the Regional Office, which was expected to make its
recommendations.
The Committee’s attention was drawn to new and emerging health problems and
challenges resulting from global warming and climatic changes. The need was expressed for
the Member Countries and WHO to formulate effective strategies to address these.
The Committee also urged Member Countries to consider implementing the
international plan of action, as endorsed by the 51st World Health Assembly for the
prevention of violence and injury, which caused a major drain on national resources by way
of medical treatment and rehabilitation of the victims.
The Committee expressed the need to support cost containment measures in the
countries, particularly in respect of drugs and vaccines, to make them affordable to the vast
majority of the population. It underscored the need for the procurement of diagnostic
material, such as test kits, drugs and insecticides to deal with malaria and kala azar.
Preparation of training material, particularly their translation into local languages was no less
important.
Considering that the countries lacked expertise in health legislation, the Committee
emphasized the need to evolve health legislation and regulatory framework. The implications
of agreements relating to WTO/GATT, TRIPS, on health should be kept in mind. Herbal
drugs and traditional medicines were acknowledged to have an important role in treatment.
A multisectoral approach involving the pharmaceutical industry and other relevant
nongovernmental organizations was called for in this regard. Clinical research in this area
also needed to be supported.
SEA/RC52/16
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In the area of food safety, the Committee recognized the need to develop closer
cooperation with other UN, bilateral and multilateral agencies. Protection of the consumer
was equally important.
The Committee underscored the importance of rational use of insecticides for the
control of communicable diseases as well as in agriculture. The broad area of surveillance
should cover assessment of the problem as well as the study of behavioural aspects. There
was a need to analyse surveillance data and provide feedback to help implement specific
activities. It felt that the Member Countries should develop disaster preparedness and early
warning systems in order to effectively deal with epidemics, as well as natural calamities.
The support provided by WHO to field epidemiology training programmes in Thailand,
Indonesia, and India was acknowledged. This would help raise standards in public health
through disease reporting surveillance analysis and response.
The Committee recognized the need for increased focus on health promotion. WHO
had provided assistance in developing health promoting schools, in line with the
recommendations made by the Meeting of Health Ministers. At the same time, significant
steps had been taken by the relevant countries in the area of mega country initiatives. There
was, however, a need to speed up activities since health promotion formed an integral and
critical part of control of communicable and noncommunicable diseases. The Committee felt
that a strong national network was necessary to develop an even stronger regional network
in health promotion activities as a whole. Realizing the importance of healthy cities, Member
countries had initiated action for strengthening this programme. The focus on healthy
settings was achieved through the plans of action for the next biennia.
The Committee was informed that the Advisory Committee on Health Research had
deliberated on the important areas of development of clinical research activities, promotion
of herbal and traditional systems of medicine, participatory development process in strategic
planning, and research on regulatory system development. It noted that appropriate
guidelines in these areas were being developed by the Scientific Working Groups set up by
SEA/ACHR.
The Committee noted the serious problem of arsenic contamination of drinking water in
shallow tubewells in some countries of the Region, leading to skin cancer and kidney failure.
It recognized the need to train health workers in the treatment of arsenic-affected patients.
SEA/RC52/16
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The need to develop a comprehensive workplan enlisting a high level of political commitment
was emphasized. The Committee urged that alternative approaches, such as chemical
treatment of contaminated water, be explored.
A resolution on the Regional Director’s biennial report was adopted (SEA/RC52/R2).
Address by Chairman, 24th SEA/ACHR
DR M.P. SHRESTHA, Chairman of the 24th session of the, South-East Asia Advisory
Committee on Health Research, presented the conclusions and recommendations of its
twenty-fourth session, held in April 1999. SEA/ACHR had recommended, among other
things, continued interaction between the regional ACHR and directors of Medical Research
Councils for defining the scope and content of national and regional health research
agendas, strengthening of health research capacity and information management and
enhancement of the roles of WHO collaborating centres and national centres of expertise. It
had also stressed the need for monitoring and evaluation of health research. Noting that
there were relatively few research activities on health policy development, it had called for
the development of good linkages between researchers and policy-makers and greater
intersectoral collaboration.
While reviewing the progress in the implementation of the recommendations of the first
joint session of the SEA/ACHR and MRCs held in 1998, SEA/ACHR had recommended that
national health or medical research councils be closely involved in monitoring and
evaluation.
In its review of important global research programmes, the Committee endorsed the
proposal to broaden the mandate of the Special Programme for Research and Training in
Tropical Diseases (TDR) to cover tuberculosis and dengue/dengue haemorrhagic fever and
directed that a comprehensive regional plan on research for the prevention and control of
malaria in border areas be developed. It recommended the formation of a task force and
development of a regional framework to review national ethics under the Special Programme
of Research, Development and Research Training in Human Reproduction (HRP). It also
requested the WHO Regional Office to convene a task force for reviewing research needs in
the prevention and control of HIV/AIDS in the Region.
SEA/RC52/16
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The 36th session of the WHO Global Advisory Committee on Health Research called for
adequate reflection of the needs and priorities of the Region in its global agenda and felt that
the regional and global ACHR system, including annual meetings of the Committee, should
be maintained. The need to enhance partnerships in health research with appropriate
organizations and institutions, including NGOs, was stressed. The mission statement and
strategic plan for global and regional health programmes on evidence and information for
policy should clearly define and delineate the role of WHO in health research at all levels. In
view of the importance of vaccine research in disease control, it felt that the Regional Office
should explore strategic ways of enhancing intercountry cooperation in the areas of vaccine
production, research and delivery.
Statement by Representatives of Nongovernmental Organizations
PROF. QUAZI SALAMATULLAH (International Council for Control of Iodine Deficiency
Disorders - ICCIDD) said that iodine deficiency was the most common preventable cause of
brain damage and his Organization was engaged in the sustainable elimination of these
disorders. He congratulated the Director-General of WHO on her excellent report on iodine
deficiency and its control, which described the spectacular progress achieved in this area.
DR SANJEEB SAPKOTA (International Federation of Medical Students Associations -
IFMSA) said that IFMSA was the biggest and oldest students’ organization, with
representation in 75 countries. Apart from encouraging the exchange of students, the
Association supported projects on public health, health education, tobacco control and
environmental awareness. It offered assistance to refugees and orphans, besides assisting
in the provision of books and organizing workshops on medical education. Seminars,
workshops and training programmes were also conducted at national and international
levels, to raise awareness among medical students and to sensitize them in public and
reproductive health.
PROF. DR M. JALISI (International Federation of Oto-rhino-laryngological Societies IFOS) said that deafness in children was a major preventable problem in South-East Asia
affecting 0.5 per cent of all children. This problem could be addressed using a three-pronged
approach of compulsory registration of all high-risk neonates, mass campaigns aimed at
early detection of the problem and efficient management. He sought WHO’s support in this
context.
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DR S.P. AWASTHY (International Association of Medical Laboratory Technologists IAMLT) stressed the importance of improving the quality of diagnosis and treatment of
diseases. He felt that the quality of education in medical laboratory science was of utmost
importance to the
national
health care system.
He
sought WHO support
in the
standardization of diagnosis and requested the establishment of an Expert Committee on
Laboratory Diagnosis Standardization and Quality Assurance to achieve harmonization
within the field of laboratory diagnostics.
DR PRABHAKAR SAMSON (International Federation of Anti-Leprosy Associations IFAL) expressed the need for sustained interest and commitment for leprosy eliminatrion.
DR TULSI BASU (Medical Women’s International Association - MWIA) stated that
MWIA, consisting of representation in 74 countries, aimed at affording medical women the
opportunity to consider common problems together, particularly in international health. Its
activities encompassed the provision of total health care to underprivileged women and
children, organizing rural health camps, hygiene literacy programmes, family planning, child
welfare and training of junior doctors and paramedicals.
PROGRAMME BUDGET (Agenda item 7)
INTRODUCING the item, the Regional Director referred to documents SEA/RC52/11 Rev.1
and Add. 1 and reminded the Committee that the Consultative Committee on Programme
Development and Management (CCPDM) had taken over the work of the Sub-committee on
Programme Budget. After requesting the Chairman of the CCPDM to present the highlights
of the CCPDM discussions, the Regional Director commented on some key Programme
Budget issues. Noting that there had been some improvement in the timeliness and quality
of implementation of the 1998-1999 programme budget, the Regional Director reiterated that
much remained to be done. Many areas for improvement had been identified by WHO’s
auditors. An external study on identifying factors to improve the implementation processes
would, along with CCPDM recommendations, form the basis for further action to be taken by
the Regional Office.
Explaining the rationale and process behind the identification of US$8.6 million regional
savings for the 2000-2001 biennium, the Regional Director confirmed that savings would be
retained within each country budget. He also confirmed that the CCPDM recommendations
SEA/RC52/16
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in this area would be considered as far as possible when finalizing the details of savings
targets for each country budget. The recommendations of the CCPDM in regard to the
detailed plans of action for 2000-2001, including those relating to the planning and
implementation of activities under ICP II, will also be carefully considered. He also indicated
that the Director-General had decided on an overall contingency hold-back of 1% from the
2000-2001 biennial funds to cope with the anticipated reduction in assessed contributions.
The Regional Director also commented that even though the Director-General planned
to take a fresh look at how individual country figures would be determined for 2002-2003,
there was nevertheless a need to begin the planning process now, as indicated in document
SEA/RC52/11 Rev.1.
The Committee was informed by the Chairman of the CCPDM about the salient points
arising from the detailed discussions and recommendations emanating from CCPDM in
regards to Programme Budget (document SEA/RC52/11 Add.1).
Concerning efficiency savings, the Committee strongly reiterated their desire for the
countries to decide the identification of areas for savings as well as the priorities to which
savings would be channelled. As the need for procurement and fellowships varied according
to individual country health situation, the Committee felt that the appropriateness of
identifying savings from these areas should in certain cases be reconsidered. It was also
suggested that the savings be allocated on a pro rata country by country basis. There was
also a proposal to base identification of savings oi i 2000-200 i planned activities instead of
actual expenditures from earlier biennia. In considering areas for savings, efforts should also
be made to include other non-activity areas such as overhead, administration costs and
staffing. In this connection, the Members noted that identification of areas for savings could
form part of the report from the ongoing efficiency review, which would be completed by
early 2000.
The Committee also emphasized the need for EB members, who will be meeting with
the Director-General at the October 1999 retreat, to be fully briefed in order to adequately
represent the views of the Committee.
Regarding the 1% contingency holdback for 2000-2001, the Committee felt that it was
unfair to impose this on countries which had been paying their assessed contributions
SEA/RC52/16
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regularly. The Regional Director was asked to pursue the matter with WHO/HQ. The
representatives could also raise the issue at the Executive Board or Health Assembly.
★**
★★★
Background was provided to the Committee to form a perspective within which to
discuss the current issues concerning savings. The background dealt with all the
circumstances relating to resolution WHA51.31 which had resulted in budget cuts. In
contrast, resolution WHA52.20 dealt with the identification of savings arising out of a need to
maintain the purchasing power of the 2000-2001 budget at par with that of 1998-1999, and
to shift funds to higher priority areas. It was not possible to identify the required savings on a
pro rata country basis as these savings would accrue from the activity component areas
decided by the Director-General in proportions reflected by country patterns of expenditure.
The 1996-1997 data were used, since information for the current and future bienniums was
incomplete.
Unique country situations would, however, be taken into consideration to the extent
possible while finalizing details and at the implementation stage. The active participation of
Executive Board members in the Director-General’s forthcoming retreat would be the best
means for the Committee’s views to be communicated to the Director-General. The key point
for negotiations was the need for regions to be able to decide the priorities for which funds
are to be reallocated within the countries.
Reduction in staffing would be complex. Programme needs, performance, staff
entitlements under UN system-wide terms of employment and budgetary constraints were all
important factors. General Service staff reductions in the Region were not considered to be
productive for generating savings because of the low salaries as compared with staff in the
professional category. Nevertheless, if programme activities were reduced, there would be a
definite impact on staffing requirement from efficiency point of view. Savings were planned in
this area in the Regional Office and it was hoped that the target could be achieved through
natural attrition.
It was also clarified that detailed Plans of Action from the countries which could not be
discussed at the CCPDM due to their late receipt, could be submitted to the WHO
representatives and would be reviewed by the Regional Office for further discussion.
SEA/RC52/16
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The Regional Director confirmed the seriousness with which he accepted the views of
the Committee concerning the overall need for greater efficiency, including in the area of
administrative overheads. He looked forward to receiving, also, the “efficiencies report” by
the group formed as proposed by the 34th meeting of the CCPDM.
CONSIDERATION OF THE RECOMMENDATIONS ARISING OUT OF
THE TECHNICAL DISCUSSIONS ON (1) TOBACCO OR HEALTH:
ACTIONS FOR THE 21st CENTURY, AND (2) INTENSIFICATION OF
HIV/AIDS SURVEILLANCE (item 8.1)
THE COMMITTEE was informed that Technical Discussions on the two subjects had been
held in conjunction with the meeting of the 36th CCPDM in accordance with the decision of
the Regional Committee (SEA/RC51/R4). Reports of both the technical discussions had
been placed before the Committee for deliberation.
Technical Discussions on Tobacco or Health: Actions
for the 21st Century
IN THE ABSENCE of Dr Suwit
Wibulpolprasert (Thailand), Chairman of the Technical
Discussions, Ms Sujatha Rao (India) presented highlights of the discussions and the
recommendations contained in document SEA/RC52/12. She emphasized the seriousness
of the tobacco problem in the Member Countries and the urgent need for action. It was
stressed that tobacco consumption had reached epidemic proportions and needed to be
monitored like any other disease. A national surveillance and response system as well as
treatment centres needed to be set up.
Member States were encouraged to develop their respective action plans for tobacco
control. There was an urgent need to frame legal regulations, forge partnerships and effect
social mobilization in order to counter the menace of tobacco use. Countries should set up
national councils comprising representatives both from the government and non
governmental sectors as well as the private sector to formulate broad-based strategies.
Economic and financial considerations should be given due attention while launching anti
tobacco drives. Taxation was considered to be the most effective measure to contain
tobacco use. The examples of Thailand and Nepal, where a proportion of the total tax
SEA/RC52/16
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revenue from tobacco products was used to counter the tobacco menace could be emulated
by other countries.
Many countries had strict regulations on monitoring of food items, but the use of
substances like nicotine was completely unregulated. Mechanisms to introduce licensing for
the sale of nicotine as a controlled drug, other than its use for therapeutic purposes, were
required. Mechanisms were also needed to be established by Member Countries for
monitoring the levels of tar and nicotine in tobacco products in the Region. WHO was
planning to hold a meeting in early 2000 to examine and review these issues. The question
of regulating international trade in view of its adverse effects on health needed to be
resolved with WTO. The Committee solicited WHO’s intervention in this regard.
In order to generate a positive influence, health professionals could themselves set
examples by refraining from tobacco use. Public awareness and education, peer pressures,
influence of religious groups/institutions and behavioural changes also had important roles to
play in tobacco control. The message: “tobacco use is injurious to health” needed to be
disseminated and displayed prominently. Alternative message, such as “tobacco revenue or
health” should be considered to gain the commitment of policy-makers. Political will and
commitment were essential to make tobacco control successful. In some countries,
legislation concerning tobacco use already existed. Its effectiveness needed to be monitored
while mechanisms for new regulations are instituted.
***
★★★
*★*
The Committee, in reviewing the recommendations emanating from the Technical
Discussions, felt that emphasis should be given to education and efforts at inducing desired
behaviour. Several members felt that the recommendations for preferred recruitment of non-
smokers in government jobs would not be feasible at this stage. The Committee indicated
that in licensing nicotine as a controlled drug, care should be taken to avoid criminalization of
its use. The Committee also felt that registration of tobacco retailers as well as the
establishment of cessation clinics would be useful.
A resolution on the subject was adopted (SEA/RC52/R7).
Technical Discussions on Intensification of HIV/AIDS Surveillance
DR SANGAY THINLEY (Bhutan), Chairman of the Technical Discussions on Intensification
of HIV/AIDS Surveillance, presented the recommendations, as contained in document
SEA/RC52/16
Page 22
SEA/RC52/13. Realizing the seriousness of the subject of HIV as a whole, the Committee
noted that, in addition to an intensified comprehensive surveillance programme, advocacy;
safe blood transfusion establishing voluntary counselling and testing facilities; HIV/AIDS
research; multisectoral involvement and response and, most importantly, the allocation of
appropriate resources were considered to be of critical importance for HIV prevention and
control. High-risk behaviours, including injecting drug use, needed to be tackled with utmost
urgency. The Committee called for further WHO support to Member Countries in specific
technical areas where WHO had the comparative advantage. These included STD
management, blood transfusion safety, HIV/AIDS care, surveillance and research.
A resolution on the subject was adopted (SEA/RC52/R5).
SELECTION OF A SUBJECT FOR THE TECHNICAL DISCUSSIONS
TO BE HELD DURING THE 38th MEETING OF THE CONSULTATIVE
COMMITTEE ON PROGRAMME DEVELOPMENT AND
MANAGEMENT (CCPDM) (item 8.2)
THE COMMITTEE selected the following two topics for the Technical Discussions to be held
during a meeting of the CCPDM in 2000: (1) Equity in access to public health, and (2)
Healthy settings. The Committee urged the Regional Office to initiate necessary action to
collect technical and scientific data on the subjects chosen for the Technical Discussions in
2000.
A resolution on the subject was adopted (SEA/RC52/R3).
REGIONAL IMPLICATIONS OF THE DECISIONS AND
RESOLUTIONS OF THE FIFTY-SECOND WORLD HEALTH
ASSEMBLY AND THE 103rd AND 104th SESSIONS OF
THE EXECUTIVE BOARD AND REVIEW OF THE DRAFT
PROVISIONAL AGENDAS OF THE 105th SESSION OF THE
EXECUTIVE BOARD AND FIFTY-THIRD WORLD HEALTH
ASSEMBLY (Agenda Item 9)
Part 1
THE COMMITTEE was informed that in accordance with the decision of the forty-eighth
session of the Regional Committee, a combined document had been prepared on the
SEA/RC52/16
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subject in order to achieve a better understanding of the regional implications of various
resolutions passed by the previous sessions of the Executive Board and the World Health
Assembly. There were 12 resolutions of regional relevance adopted by the 52nd World
Health Assembly and 3 resolutions of the 103rd session of the Executive Board held in 1999.
The Committee took into consideration the deliberations and recommendations of the 36th
meeting of the CCPDM which had already reviewed these resolutions. The CCPDM
discussions focused on two specific resolutions: (1) Scale of assessment for the financial
period 2000-2001 (WHA52.17), and (2) Towards a WHO framework convention on tobacco
control (WHA52.18).
Regarding resolution WHA52.17, the Committee noted the need to review the basis of
determining assessed contributions. Even though the scale of assessment was determined
by the UN General Assembly, it would be useful to have relevant information on the base
year on which assessments were determined. The Regional Office was requested to provide
this information later.
As regards resolution WHA52.18 relating to Framework Convention on Tobacco
Control, the solidarity among Member Countries of the Region should be used in protecting
regional interests. Since the Framework Convention would take a few years to be approved,
Member Countries should proceed with the development of their strategies and programmes
for tobacco control for early implementation of the Convention. It should, however, be
ensured that countries were not adversely affected for not implementing this international
Convention.
Part 2
THE COMMITTEE was informed that in view of the correlation of the work of the Regional
Committees with that of the Executive Board and the World Health Assembly, it was
customary for it to review the agendas of the forthcoming sessions of these two bodies. This
year, however, only a list of subjects likely to be discussed during the 105th session of the
Executive Board was available. That list had been examined by the CCPDM. The Committee
noted the recommendations made by the CCPDM on the need for the Executive Board
members from the Region to be briefed adequately by WHO Representatives on the process
of proposing agenda items of interest to the Region as well as on the need to brief relevant
country-level counterparts after meetings of the Board and Health Assembly. This would
SEA/RC52/16
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allow national counterparts to be fully aware of the country level implications of Executive
Board/World Health Assembly resolutions. The Committee also felt that since World Health
Assembly resolution WHA 51.31 clearly indicated that the interest of the least developed
countries would be protected to the extent possible, it should be ensured that that would be
the case through the year 2005. The Committee also felt that it would be useful to include
persons who are technically sound in health-related areas as part of country delegations to
the meetings of WHO governing bodies.
In view of the problem of arsenicosis in Bangladesh and some parts of West Bengal in
India, the Committee felt that this issue should be taken up at the highest forum; therefore,
efforts should be made to get this item included in the agenda.
Statement by the Representative from the International Federation
of Pharmaceutical Manufacturers
DR ALAIN AUMONIER (International Federation of Pharmaceutical Manufacturers - IFPM)
said that resolutions WHA52.19 and WHA 52.23 relating to the revised drug strategy and
strengthening health systems in developing countries, provided encouragement to both
national decision-makers and international institutions to give more priority to health in their
agendas as well as for more substantive ^resource allocation.
He conveyed the
pharmaceutical industry’s appreciation fqr WHO® initiative in creating a collaborative climate
fqf research-dn^esseniial drugs and hoped for ^productive common initiativ^in improving
access to drugs for patients in developing countries.
Statement by the Representative of the World Organization
of Family Doctors
DR MD. NURUL ISLAM, (World Organization of Family Doctors - WONCA), expressed his
organization’s commitment to implement WHA resolution WHA48.8 on the reorientation of
medical education and medical practice for Health for All. WONCA was undertaking a
number of collaborative activities in various parts of the Region.
ROLL BACK MALARIA (RBM) AND MAINSTREAMING OF ANTI
MALARIA ACTIVITIES IN HEALTH SECTOR DEVELOPMENT
(Item 10)
THE REGIONAL DIRECTOR introduced the subject and referred to the importance of
partnership among agencies concerning “Roll Back Malaria”, as endorsed by the World
SEA/RC52/16
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Health Assembly. He said that it was important to link it with other disease control
programmes. Sustainable broad-based partnerships and intersectoral coordination were
essential for achieving the objectives. In some countries, the malaria menace had reemerged after having been under control for many years; lack of resources hampered
progress in containing its resurgence.
RBM initiative had provided an impetus to intensified country efforts. Due emphasis
was being laid on various important aspects, such as political commitment at the highest
level, involvement of nongovernmental organizations and the private sector, intersectoral
collaboration, epidemic control, vector control, substantial reduction in malaria cases, control
of drug resistance, environmental management, adoption of integrated approach and
capacity building, etc. The existing malaria control programmes in the Member Countries
needed to be reviewed and the possibility for additional resource mobilization by adopting a
partnership approach explored. A plan of action for malaria control programmes needed to
be developed and a review of capacity-building undertaken at various levels. WHO had an
important role to play in assisting countries to mobilize funds from voluntary/external donors.
There was a need to establish technical resource networks among countries of the Region
with technical guidance and support from WHO. The Organization’s assistance was also
sought in tackling cross-border malaria problems.
The Committee took note of certain points for consideration by the Member Countries:
(1) enlist national commitment to support the RBM and the policies needed to sustain it; (2)
propose changes and mechanisms required to mainstream RBM in health sector
development; (3) identify human and other resources to be moblized for capacity-building, in
prevention early diagnosis and prompt treatment; (4) explore ways of initiating and
sustaining partnerships in strategic investment, and (5) identify mechanisms to foster
regional support. The Committee emphasized that since 2000-2001 was a pivotal period,
countries should select interventions with locally acceptable guidelines and implement the
preparatory phase of the Roll Back Malaria initiative. Recognizing that malaria was a complex problem,
it called for finding effective solutions within the available resources and expertise. There was a need to
strengthen the regional technical support networks to directly address priority issues. The Committee
stressed that the development of manpower at all levels should be given priority for achieving the
objectives of RBM.
**★
**★
***
SEA/RC52/16
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The Committee urged WHO to assist in (1) assessing the technical expertise available
in the countries; (2) identifying gaps for training and human resource development, and (3)
capacity building to strengthen the knowledge base both in public and of the large number of
private medical practitioners in the countries in the prevention, early diagnosis and prompt
treatment of malaria cases.
A resolution on the subject was adopted (SEA/RC52/R5).
INTERCOUNTRY COOPERATION IN THE SUPPLY OF
ESSENTIAL DRUGS (Agenda item 11) (document SEA/RC52/6)
THE COMMITTEE-noted that WHO had been assisting Member Countries in the formulation
and implementation of national drug policies in order to save lives and to reduce morbidity
and mortality from common illnesses. Towards this goal, emphasis had been placed on
advocating the essential drugs concept, drug supply management, quality assurance and
rational use of drugs. Other aspects of national drug policy, such as drug legislation and
regulatory control, essential drugs production, dissemination of drug information, drug
financing, training of human resources and technical cooperation among countries of the
Region, were being promoted. Even though the Member Countries of the Region had
developed national drug or pharmaceutical policies, accessibility to essential drugs differed
from country to country and within the same country. These differences became prominent
during times of economic crisis and emergency situations due to disruption in drug supply. In
the circumstances, intercountry cooperation in sustaining the supply of essential drugs
became a critical issue.
***
***
***
The Committee appreciated the increasing regional need for intercountry cooperation in
the areas of exchange of available information on drugs and pharmaceuticals; strengthening
of national drug regulatory bodies; supporting WHO’s role in encouraging national drug
standards; sharing of technology skills for the production of vaccines and high-tech drugs as
well as human resource development; supporting rational use of essential drugs;
harmonization of drug regulation; better drug procurement at national and sub-national levels
of bulk raw materials, adequate supply, feasible access to the marginalized population; and
the rights of large and small countries in getting appropriate essential drugs.
It
SEA/RC52/16
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The Committee emphasized that if the idea of bulk purchasing was to be undertaken,
Member Countries should decide on the list of basic essential drugs and the quantities to be
procured so as to collectively indent for the aggregated quantity in the global market, in order
to obtain drugs at competitive prices. It was felt that the validity of WHO acknowledgement of
national GMP (Good Manufacturing Practices) should be upheld for this process. In this
connection, the Committee noted the successful example of bi-regional cooperation between
WHO and ASEAN in the area of pharmaceuticals.
STRENGTHENING POISON CONTROL CENTRES IN
THE REGION (Agenda item 12) (document SEA/RC52/8)
THE COMMITTEE noted that, with the rapid economic and industrial growth in the Region,
the demand for and use of chemicals in agriculture, health and industrial sectors had
increased enormously, leading to indiscriminate and unsafe use of chemicals, particularly
pesticides. This had resulted in an increasing incidence of accidental and intentional
poisoning with consequent morbidity and mortality. A significant proportion of the population
was unaware of the toxic risks of chemicals, which were often poorly labelled and improperly
stored. Pesticide was a major health concern in all SEAR countries.
Occupational exposure to industrial chemicals, ground water and environmental
contamination with arsenic, fluorides, lead and pesticides and adulteration of food also
posed serious health problems. There had also been industrial accidents involving toxic
chemicals. Though toxic chemicals posed a serious health risk in all SEAR countries, the
exact magnitude of the problem was not known because of inadequate data. It was therefore
essential for the countries to identify the existing capabilities and facilities for poison control
and take steps towards resource mobilization, capacity building and
institutional
strengthening. This called for appropriate policy decisions by the Ministry of Health with the
active partnership of various NGOs and the private sector. The Regional Office proposed to
organize, with the help of the International Programme on Chemical Safety, WHO/HQ and
other centres of excellence, a comprehensive poison control programme in the Region to
provide necessary technical support to the countries.
A resolution on the subject was adopted (SEA/RC52/R6).
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UNDP/WORLD BANK/WHO SPECIAL PROGRAMME FOR RESEARCH
AND TRAINING IN TROPICAL RESEARCH DISEASES: JOINT
COORDINATING BOARD (JCB) - ATTENDANCE AT 1999 JCB
(Item 13.1)
THE COMMITTEE was informed that, on behalf of India, Sri Lanka and Thailand, the
representative from Sri Lanka had reported on the deliberations of the 22nd session of the
JCB, held in Geneva in June 1999 to the 36th CCPDM.
JCB emphasized the important role of the TDR Programme in improving the quality of
life of populations exposed to tropical diseases and noted that the WHO contribution to the
Programme’s budget had been increased by 25% for the next biennium. The need for
providing adequate administrative support to the TDR Programme was stressed. The
participants discussed the Roll Barik Malaria initiative, its principles and key elements, such
as early detection, prompt treatment, multiple prevention methods, well-coordinated action,
dynamic global movement and focused research.
In view of the re-emergence of tuberculosis and its close association with HIV
infections, JCB agreed to include tuberculosis control in the TDR programme. A proposal to
include research pertaining to dengue control in the TDR programme was also endorsed.
The need for, and the importance of institutional strengthening, particularly in the least
developed countries was also underlined.
In response to a query, it was clarified that in 1998, out of the estimated US $73 milliion
spent under the programme, the SEA Region’s share was $989,259, which was distributed
among India, Indonesia, Myanmar, Nepal, Sri Lanka and Thailand. The Committee was
informed that research proposals were funded through a competitive process. If the Member
Countries proposed high priority and good quality research proposals, the chances of the
Region getting a better share were good. In particular, the addition of research on TB and
dengue as part of TDR, would enlarge the scope of participation of the Region. The
Committee urged that technical assistance be provided to Member Countries to develop
good proposals.
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SPECIAL PROGRAMME FOR RESEARCH, DEVELOPMENT AND
RESEARCH TRAINING IN HUMAN REPRODUCTION - REPORT ON
THE POLICY AND COORDINATION COMMITTEE (PCC) SESSION
AND NOMINATION OF A MEMBER TO PCC IN PLACE OF THAILAND
WHOSE TERM EXPIRES ON 31 DECEMBER 1999 (item 13.2)
THE COMMITTEE was informed that, on behalf of India, Indonesia and Thailand, the
representative from Thailand reported on the deliberations of the 12th meeting of the Policy
and Coordination Committee, held in June 1999, to the 36th meeting of the CCPDM.
PCC noted that WHO headquarters had decided to establish a small working group to
study the interaction between the work of clusters with those of TDR and HRP.
PCC also discussed matters relating to the Meeting of the Scientific and Ethical Review
Group. It endorsed the mechanisms adopted by the Programme to ensure that the views of
the developing countries contributed to priority setting in the Programme’s activities and
recommended that WHO address ethical responsibilities of researchers at the country level.
The reports of the STAG and Gender Advisory Panel were noted. PCC also discussed the
1998-1999 interim financial report and the current funding situation and noted with some
concern the financial constraints that existed.
The Committee nominated Bangladesh as a member of PCC for three years from 1
January 2000 in place of Thailand.
Statement by the Representative of International Planned
Parenthood Federation
DR AHMAD NEAZ (International Planned Parenthood Federation - IPPF), offered his
organizaton’s full cooperation to WHO in undertaking further research in the field of human
reproduction. Highlighting the activities already undertaken by IPPF, Dr Neaz called for
further research to cope with emerging needs. He urged WHO to continue its search for
scientific innovations, particularly in the areas of safe motherhood and the HIV/AIDS
pandemic as well as in the field of socioeconomic, cultural and behavioural aspects of
human reproduction. A mechanism for the delivery of client-friendly quality service to the
underserved groups needed to be developed. He urged further strengthening the WHO-IPPF
partnership in this area.
»
SEA/RC52/16
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WHO ACTION PROGRAMME ON ESSENTIAL DRUGS INFORMATION PAPER ON THE SESSION OF THE
MANAGEMENT ADVISORY COMMITTEE (MAC) (Item 13.3)
THE COMMITTEE was informed that, on behalf of Bangladesh and Myanmar, the
representative from Bangladesh reported on the deliberations of the 11 th meeting of the
Management Advisory Committee (MAC) held in March 1999 to the 36th meeting of the
CCPDM.
MAC noted that there was a need to develop capacity in drugs regulation in some
countries. Surveillance for the safety and efficacy of drugs was necessary. Effective
enforcement of law on drugs was important in order to achieve effective drug regulation. The
establishment of a national quality control laboratory would facilitate quality assessment of
the drug before and after procurement. Apart from the WHO Regular budget, enhanced
extrabudgetary funds and increased financial contributions from the government would go a
long way in implementing activities under the Essential Drugs and other Medicines (EDM)
programme within the countries. Additionally, alternative health care financing mechanisms,
such as user fees, fees for drugs, community donations, health insurance schemes etc.
could also mobilize additional funds.
Statement by the Representative of International Organization for
Cooperation in Health
DR THELMA NARAYAN (International Organization for Cooperation in Health - IOCH) said
that her Organization provided technical and financial support to NGOs to promote the PHC
approach in strengthening district health systems to improve the health status of poor
people. She emphasized the significance of collaboration between government and
nongovernmental organizations in the implementation of national programmes, particularly
the control of malaria, tobacco, TB, etc.
TIME AND PLACE OF FORTHCOMING SESSIONS OF THE
REGIONAL COMMITTEE (item 14)
THE COMMITTEE accepted the confirmation by the Government of India (SEA/RC51/R5) to
host its 53rd session in early September 2000.
J
SEA/RC52/16
Page 31
The Committee accepted the invitation of the Government of the Union of Myanmar to
host the fifty-fourth session in 2001, and noted with appreciation the invitation of the
Government of Indonesia to host its fifty-fifth session in Indonesia in 2002.
A resolution on the subject was adopted (SEA/RC52/4).
Consideration of Draft Resolutions
THE COMMITTEE adopted eight resolutions. In respect of the resolution on tobacco, the
Chairman said that operative paragraph (a) proposing the constitution of a multisectoral
national council under the chairpersonship of the Head of State/Government might not be
practicable. However, no change in the text of the resolution was proposed since it had
already been adopted.
MEDIA ALERT
World No-Tobacco Day (31 May 1999)
Press Release (embargoed until 27 May): TO FOLLOW
Plus: Press Conference
Where:
Geneva, Switzerland, Palais des Nations, Salle de Presse III
When:
27 May 1999, 14h00
What:
Winner of Director-General’s “Tobacco Free World Prize”
announced
Who:
Winner is a major international figure in the fight against
Tobacco
Dr Derek Yach, Programme Manager of WHO’s Tobacco
Free Initiative, will also be available to answer questions on
this year’s World No-Tobacco Day theme: cessation
1
For further information, journalists can 1) contact Gregory Hartl, Health Communications and Public
Relations, WHO, Geneva. Telephone (41 22) 791 4458. Fax (41 22) 791 4858. Email: hartlg@who.int,
2) consult the World No-Tobacco Day advisory kit or the Tobacco Free Initiative's homepage:
http://www.who.int/toh
All WHO Press Releases, Fact Sheets and Features as well as other information on this subject can be
obtained on Internet on the WHO home page http://www.who.int/
Message
from Dr Gro Harlem Brundtland,Director-General of the
World Health Organization, for World No-Tobacco Day
Giving up smoking is not easy. We know that nicotine is powerfully addictive, and all of
us know people who have tried to give up smoking, only to find themselves drawn back
to it a few months later.
This is a challenge for us all, and we have to rise to it because we know that getting more
smokers to quit is the key to reducing the projected tobacco-related death toll over the next
two decades. A recent survey in a large developing country revealed that two-thirds of
smokers mistakenly believe that smoking does little or no harm; few are interested in quitting,
and fewer still have successfully quit. At present, most smokers who do successfully give up
do so without formal help. But we need to greatly increase rates of successful quitting.
Today we know that successful and cost-effective treatments exist. Nicotine replacement
medicines such as nicotine gum, patches, nasal spray and inhalers as well as non-nicotine
medicines such as bupropion can double people’s chances of succeeding.
These need to be more widely available, but the cost also needs to be reduced to bring
them within the reach of smokers everywhere. The good news is that there are real
health gains to be made from stopping at any age. Those who give up in their early 30s
enjoy a life expectancy similar to people who never smoked. I therefore invite all
smokers to take a giant step towards better health and “leave the pack behind”.
WORLD HEALTH ORGANISATION
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FACT SHEET
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WEBSITE
www.who.int
1211 GENEVA 27 SWITZERLAND - TELEPHONE: 791.21.11- CABLES: UNISANTE-GENEVE - TELEX: 415.416 - FAX: 791.07.46 - E-MAIL: inf@who.int
Fact Sheet No 221
April 1999
TOBACCO - HEALTH FACTS
The truth is that one out of every two long-term smokers will ultimately be killed by
tobacco. In developed countries, half will be killed in old age, after age seventy, but the
other half will be killed in middle age, before age seventy, and those who die from smoking
before age seventy will lose more than 20 years of life expectancy.
The truth is that four million people die yearly from tobacco-related diseases, one
death every eight seconds. If current trends continue, WHO estimates that the toll will rise
to ten million by 2030, one death every three seconds. Tobacco is fast becoming a greater
cause of death and disability than any single disease.
It doesn’t have to be that way. WHO has decided to focus attention and resources
on tobacco use, to try to prevent at least some of these predicted deaths, and to prevent
hundreds of millions to more in the decades to come after 2030.
How many deaths?
Tobacco is a silent killer. Peaks in tobacco mortality reflect peaks in tobacco
consumption three to four decades earlier. Current smoking mortality is the result of past
lifetimes of tobacco consumption.
•
•
•
•
•
From 1950 to 2000, tobacco will have killed more than 60 million people in developed
countries alone, more than died in World War II.
If current trends continue, tobacco will kill more than 100 million people in the first two
decades of the 21st century.
If current trends continue, 500 million people alive today will be killed by tobacco.
Of the 300 million Chinese men now aged 0-29, at least 100 million will eventually be
killed by tobacco. Half the deaths will be among those aged 35-69.
In the Former Socialist Economies (FSE), around 14% of all deaths were traced to
tobacco use in 1990. By 2020, this figure is slated to rise to 22%. And smoking is the
Fact Sheet No 221
Page 2
major risk factor responsible for a predicted 56% increase in male deaths from chronic
diseases in FSE countries from 1990 to 2020.
How much illness?
•
•
•
•
Tobacco is a known or probable cause of some 25 different diseases. For some, like
lung cancer, bronchitis and emphysema, it is the major cause.
Other people’s tobacco smoke contains essentially all of the same carcinogens and
toxic agents that are inhaled by the smoker. Other people’s tobacco smoke is harmful
to non-smokers because it causes lung cancer and other diseases, and aggravates
allergies and asthma.
Tobacco consumption has been explicitly linked to high incidence and gravity of
cardiac disease.
Maternal smoking is associated with a higher risk of miscarriage, lower birthweight of
babies and inhibited child development. Parental smoking is also a factor in sudden
infant death syndrome and is associated with higher rates of respiratory illnesses,
including bronchitis, colds and pneumonia in children.
How many smokers?
•
•
•
WHO estimated that there were 1.1 billion smokers in the world at the beginning of the
1990s, 300 million in developed countries and 800 million in developing countries.
About one-third of the world’s adults were smokers at the beginning of this decade, and
there is little sign that this proportion has changed substantially since.
At the beginning of the 1990s, 47% of men and 12% of women were smokers. In
developing countries, it was estimated that 48% of men and 7% of women were
smokers, while in developed countries, 42% of men and 24% of women were smokers.
Tobacco use among adolescents remains stubbornly persistent. Smoking prevalence
among adolescents rose in the 1990s in several developed countries . While new
markets are being opened by tobacco industry actions, old markets have not been
closed - tobacco is a global threat.
Tobacco and smoke concern us all, smokers and non-smokers alike. Tobacco is
everybody’s problem. It is a major public health issue that demands urgent action
now.
For further information, journalists can contact WHO’s Office of Public Information, Geneva.
Telephone (41 22) 791 2584. Fax (41 22) 791 4858. E-Mail: info@who.ch
All WHO Press Releases, Fact Sheets and Features as well as other information on this subject can
be obtained on Internet on the WHO home page http://www.who.ch/
b WORLD HEALTH ORGANIZATION
FACT SHEET
WEBSITE
www.who.int
1211 GENEVA 27 SWITZERLAND - TELEPHONE: 791.21.11 - CABLES: UNISANTE-GENEVE - TELEX: 415.416 - FAX: 791.07.46 - E-MAIL: inf @ who.int
Fact Sheet No 222
April 1999
TOBACCO DEPENDENCE
The worldwide epidemic of tobacco-related disease and death continues to worsen as
tobacco use spreads. Millions of lives could be saved with effective treatment for tobacco
dependence. However, such treatment is currently unavailable for many tobacco users
throughout the world. For this reason, the World Health Organization, in preparation for
World No-Tobacco Day 1999 (May 31), offers the following information and
recommendations to governments, organizations, health-care professionals, and tobacco
users and non-users worldwide.
About Tobacco and Treatment
•
Tobacco use is widespread. At least one-third of the global adult population, or 1.1
billion people, use tobacco. Although overall tobacco use is decreasing in many
developed countries, it is increasing in most developing countries. An estimated 48% of
men and 7% of women in developing countries smoke; in industrialized countries, 42%
of men and 24% of women smoke, representing a marked increase among women.
Tobacco use is a paediatric epidemic, as well. Most tobacco use starts during
childhood and adolescence.
•
Tobacco kills. A long-term tobacco user has a 50% chance of dying prematurely from
tobacco-caused disease. Each year, tobacco causes some 4 million premature deaths,
with 1 million of these occurring in countries that can least afford the health-care
burden. This epidemic is predicted to kill 250 million children and adolescents who are
alive today, a third of whom live in developing countries. By the year 2030, tobacco
likely will be the world’s leading cause of death and disability, killing more than 10
million people annually and claiming more lives than HIV, tuberculosis, maternal
mortality, motor vehicle accidents, suicide, and homicide combined.
•
Tobacco products are highly addictive. Because tobacco products are carefully
designed to undermine efforts to quit using them, quitting is not simply a matter of
choice for the majority of tobacco users. Instead, it involves a struggle to overcome an
[I PRfSSBfHCt
Fact Sheet No 222
Page 2
addiction. Tobacco use typically is woven into everyday life, and can be physiologically,
psychologically, and socially reinforcing. Many factors combine with tobacco's addictive
capacity to make quitting difficult, including media depictions and cultural and societal
acceptance of tobacco use.
•
J
Quitting tobacco at any point in life provides both immediate benefits and
substantial long-term benefits to health. No amount of tobacco use is safe.
Abstinence from tobacco products and freedom from exposure to second-hand smoke
are necessary for maximizing health and minimizing risk. Effective treatment for
tobacco dependence can significantly improve overall public health within only a few
years.
The currently available, proven treatment methods work. Hundreds of controlled
scientific studies have demonstrated that treatment can help tobacco users achieve
permanent abstinence. Effective treatment can involve a variety of methods, such as a
combination of behavioural treatment and pharmacotherapy (nicotine replacement and
non-nicotine medications). Population-based methods such as telephone helplines and
national and international tobacco-free days also can help deliver treatment.
Implementing Treatment
1. Make Treatment a Priority. Governments should rank treatment as an important
public-health priority.
2. Make Treatment Available. Health-care systems should offer practical interventions to
all tobacco users, regardless of economic level, age, and sex. This effort includes
preventing and treating tobacco use in children and adolescents, reducing family
exposure to tobacco, and providing treatment medications when appropriate. This
process is facilitated by incorporating tobacco dependence treatment into drug abuse
treatment, reproductive and maternal-child services, and other programs.
3. Assess Tobacco Use and Offer Treatment. Health-care providers should assess and
document tobacco use and should provide treatment as an essential part of quality
health care. Health-care providers should assume responsibility for learning about
tobacco use and treatment, and for providing proven interventions. Providers,
educators, and community leaders should take advantage of teachable moments and
opportunities for prevention and intervention.
4. Health-care professionals should set an example for their peers and patients by
quitting tobacco use. Governments and education systems can help this process by
funding treatment and education programs for health professionals in training.
5. Fund Effective Treatment. Governments and health care organizations should fund
treatment based on methods that have been demonstrated to be effective, and should
make treatment widely available. Increasing the institutional and human capacity for
providing this service involves training health-care workers to deliver treatment,
implementing curriculum for students in the health professions, developing resource
centres, encouraging the creation and maintenance of centres of excellence in treating
tobacco dependence, and reducing the barriers between tobacco users and treatment.
Fact Sheet No 222
Page 3
6. Motivate Tobacco Users. Governments, health providers, and community groups
share a responsibility for motivating tobacco users to quit and remain abstinent. They
should educate the public about the health risks of tobacco use, encourage tobacco
users to seek treatment, and help make treatment available, affordable, and
accessible.
7. Monitor and Regulate Tobacco. Governments should monitor and report on tobacco
use, and should tax and regulate the sale and marketing of tobacco products. These
efforts reduce initiation of tobacco use and help fund effective treatments. Responsible
regulation of tobacco products reduces tobacco use and limits risk. Regulatory
authorities should prohibit marketing strategies that give false reassurances about
minimized health risks and divert attention from quitting. Additionally, all possible steps
should be taken to reduce the harmfulness of tobacco products. Governments should
collaborate to provide meaningful and accurate ratings of nicotine and other chemicals
in tobacco products, and to reduce the toxicity and addictiveness of those products.
Treatment medications should be at least as accessible as tobacco products.
8. Develop New Treatments. Investing in the science and technology of treatment
improves the efficacy of treatment for those in diverse populations and under-served
groups. Effective treatments should be developed for groups for whom treatment has
not been available, such as children and adolescents.
Universal application of all of these measures is the most effective approach to
tobacco treatment. The current escalation in tobacco use and in tobacco-related death and
disease can only be reversed by investment in comprehensive tobacco control, which
includes treatment for tobacco dependence. Governments, health-care and education
systems, community and religious groups, as well as news and entertainment media
should collaborate in promoting tobacco treatment.
World No-Tobacco Day on May 31, 1999, provides the opportunity for governments,
health-professional bodies, and the media to join with WHO in committing themselves to
take local, national, and global action that could bend the trend of the tobacco epidemic.
• (This statement, which is based upon the best available scientific information, was
written by a group of experts from developed and developing countries hosted by the
Mayo Clinic Nicotine Dependence Center and prepared for WHO to disseminate worldwide
prior to 1999 World No-Tobacco Day. A full report will be available later in 1999; see
http://www.who.orgj
For further information, journalists can contact WHO's Office of Public Information, Geneva.
Telephone (41 22) 791 2584. Fax (41 22) 791 4858. E-Mail: info@who.ch
All WHO Press Releases, Fact Sheets and Features as well as other information on this subject can
be obtained on Internet on the WHO home page http://www.who.ch/
WORED HEALTH ORGANIZATION
FACT SHEET
1211 GENEVA 27 SWITZERLAND - TELEPHONE: 791.21.11 - CABLES: UNISANTE-GENEVE - TELEX: 415.416 - FAX: 791.07.46 - E-MAIL: inf@who.int
Fact Sheet No 223
April 1999
TOBACCO - SUPPORTING THE TOBACCO INDUSTRY IS BAD
ECONOMICS
Tobacco not only kills people, it also saps national treasuries. Just as there are no safe
levels of tobacco consumption, there are no safe investments in tobacco. The economic impact of
tobacco has been analyzed in many countries in recent years. Studies from Brazil, China, South
Africa and Switzerland complement earlier analyses done in Canada, the United Kingdom and the
United States. Their combined message is unequivocal - the alleged economic benefits of tobacco
are illusory and misleading.
The devil is in the detail. Tobacco has large, direct and intangible costs associated with it costs that often not taken into account when tobacco’s virtues are extolled. Rarely do those who
argue for continuing investment in tobacco take account of the real economic effect of declines in
the tobacco industry. Most serious analyses of all the economic effects show that a decline in the
tobacco industry would not result in less employment. In fact, as employment in the tobacco sector
decreases, overall employment may stay the same or even increase. Simply put, as one section of
the economy declines, others open up. A recent study (R. van der Merwe, The Economics of
Tobacco Control in South Africa, 1998) concluded:
“The results presented indicate unequivocally that a cessation of cigarette purchasing
would lead to significant net increases in South African output and employment.”
A World Bank study entitled “The Economic Costs and Benefits of Investing in Tobacco’’
(March 1993) has estimated that the use of tobacco results in a global net loss ofUS$200 billion
per year, with half of these losses occurring in the developing world. This cost does not reflect loss
due to reduced quality of life of smokers and their families. The same study also estimated that
smoking prevention is among the most cost-effective of all health interventions.
•
In a developing country with a per capita gross domestic product of US$ 2000, effective
smoking prevention costs approximately US$20 to US$40 per year of life gained.
On the other hand, lung cancer treatment, which can prolong the lives of only about 10% of
affected people, would cost US$ 18 000 per year of life gained.
For further information, journalists can contact WHO’s Office of Public Information, Geneva.
Telephone (41 22) 791 2584. Fax (41 22) 791 4858. E-Mail: info@who.ch All WHO Press Releases, Fact
Sheets and Features as well as other information on this subject can be obtained on Internet on the WHO
home page http://www.who.ch/
i r
PRESS OFFICE
.1
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WORLD HEALTH 0RGANIZATION
FACT SHEET
g
WEBSITE
www.who.int
1211 GENEVA 27 SWITZERLAND - TELEPHONE: 791.21.11- CABLES: UNISANTE-GENEVE - TELEX: 415.416 - FAX: 791.07.46 - E-MAIL: inf@who.int
Fact Sheet No 224
April 1999
TOBACCO - WHAT GOVERNMENTS CAN DO - LEGISLATE
AND EDUCATE
The spectacular rise and spread of tobacco consumption world-wide is a challenge
and opportunity for the Member States of the World Health Organization. Through national
policies, governments have a key role to play in controlling tobacco as effectively as
possible.
WHO recommends comprehensive tobacco control strategies, with strong
emphasis on legislation and education. Reducing tobacco’s harmful effects requires
governments to legislate and educate. There is a need for urgent national and international
action to restrict the spread of tobacco use.
Tobacco kills four million people a year, one death every eight seconds. If current
trends remain unchecked, tobacco will also eventually kill 250 million children alive today.
This death toll is avoidable Tobacco control must come from all sectors of society, from
economic, health and social sectors.
Effective policies and interventions can make a real difference to tobacco use and
associated health outcomes. The combined impact of legislation, increased tax and
comprehensive community-based strategies has steadily decreased tobacco consumption
in many developed countries. Early indications from developing countries that have
adopted a similar mix of interventions suggest that they too will be effective.
Examples of successful legislation can be found: New Zealand adopted
comprehensive tobacco control policies in 1990. By 1996 tobacco consumption per capita
among young adults (15+) had dropped by 21%. Thailand introduced comprehensive
tobacco control policies in 1992. Smoking prevalence among young Thai adults aged 1519 dropped for 12.1% to 9.5%, a decline of over one-fifth. Thailand also registered
substantial decreases in adult smoking prevalence from 1991 to 1996.
WHO PRESS OFFICE
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Fact Sheet No 224
Page 2
WHO recommends some key actions that governments could undertake to create
comprehensive national tobacco control programmes:
•
Legislate:
Ban all tobacco advertising and promotion
Ban sales to children
Require effective health warnings on all tobacco products
Require detailed reporting of constituents of tobacco and tobacco smoke
Regulate tobacco products
Protect people from involuntary exposure to tobacco smoke by establishing smokefree public places and workplaces
•
Bring tobacco smuggling under control through stricter law enforcement and
improved international co-operation
•
Increase the price of all tobacco products beyond inflation; use part of the revenue
for tobacco control, and part to promote economic alternatives to tobacco growing and
manufacturing
Educate:
• Invest in health education and promotion
• Provide tobacco use cessation programmes
• Support media involvement in the need for tobacco control, the availability of policies
that work and the role of the tobacco industry in thwarting implementation of effective
tobacco control policies
• Counter tobacco industry misinformation campaigns by telling the truth about tobacco
• Ensure adequate institutional support for tobacco control capacity building, applied
research, routine surveillance and programme evaluation
For further information, journalists can contact WHO’s Office of Public Information, Geneva.
Telephone (41 22) 791 2584. Fax (41 22) 791 4858. E-Mail: info@who.ch
All WHO Press Releases, Fact Sheets and Features as well as other information on this subject can
be obtained on Internet on the WHO home page http://www.who.ch/
WORLB HEALTH OBGANIZfiTiOH
FEATURE
WEBSITE
www.who.int
1211 GENEVA 27 SWITZERLAND - TELEPHONE: 791.21.11 - CABLES: UNISANTE-GENEVE - TELEX: 415.416 - FAX: 791.07.46 - E-MAIL: int@who.int
Feature No 192
March 1999
IMAGES THAT SPEAK: WORLD-RENOWNED
PHOTOGRAPHER BACKS GLOBAL FIGHT AGAINST
TOBACCO
He launched a campaign in Tokyo, a concept in New York and New
Delhi. The tobacco industry was swift in spotting his talent. He put his talent to
work to sell tobacco wrapped in multi-colour dreams. Thanks to his campaign,
a company saw its sales go up by 28% in one market in six months. Others
rushed in with offers. RJR, Phillip Morris, British American Tobacco
clamoured for his attention. The image was the message. A two-pack per day
smoker himself in those heady days, he thought this was art and life joining
hands to celebrate.
There are tears in his eyes today as Ashvin Gatha looks back on the
tobacco campaigns he launched and helped design. “I thought I was selling a
simple cigarette - little did I know that I was helping sell a product that kills
people,” says this Indian-born photographer. “I want to be able to fight
alongside those who are exposing the tobacco industry for what it really does
- marketing to children, selling a drug that is addictive and fooling people into
believing they can quit when they want,” Gatha says.
People underestimate the power of images, says this amiable
photographer who has designed the World Health Organization’s (WHO’s)
image for World No Tobacco Day, 1999. It is a white marble ashtray on which
is poised a bright red orchid. Life and flower, instead of ash and death says
Gatha talking about his concept to back WHO’s pitch this year for smoking
cessation. The choice of a red flower is no accident. Reminiscent of a famous
tobacco brand, the photographer wants to turn the power of colours and
images on those very people in the tobacco industry whose mission it is to sell
PRESS OFFICE
poisoned dreams. If he could pour profits of up to 28% into their coffers, he
can also do the reverse. Gatha’s eyes twinkle.
He has come a long way in more ways than one. Orphaned at one,
Gatha grew up on the streets of Mumbai (Bombay) until an uncle living in
Singapore rescued him at the age of 14 giving the illiterate child a home,
schooling. Gatha borrowed a camera from his adoptive brother and his first
picture topped a photography competition run by the Straits Times in
Singapore. A career was born.
Living colour is splashed across all of Gatha’s photographs, from the
streets of India to the marshes of his wife’s native Switzerland, from the heady
heights of New York to the industrial products of multinational companies the
pictures tell stories words can’t. The orchid on the ashtray tells a story about
WHO’s public health campaign in much the same way - gently but firmly.
Gatha is the first to concede that it is not going to be easy taking on the
tobacco industry that pours millions every year into crafting its image. But
again, he is no stranger to adversity and opposition. When the adolescent
Gatha told his adoptive family he wanted to be a photographer and not an
office clerk, he was scorned. He had to wait till he was 23 to get his own
camera. Before that he was bitten by the New York bug that grips most artists
rearing to go. His family thought otherwise and packed him off to Mumbai’s
film industry. The only words of advice his uncle gave him were “there’s
always room at the top - remember that after sunset there is always sunrise”.
Unimpressed with the hierarchical and political nature of the film
industry at that time, he quickly opted out and, with not a rupee in his pockets,
went to live at the end in the Mumbai railway station, on bench no 4, platform
no 2. Greasing the palm of the police with 1 rupee for the privilege of sleeping
on the bench each night, and occasionally sharing the meals of a ticket
controller, Jashwan Singh, Ashvin began earning a pocketful of rupees by
photographing restaurant patrons. Disheartened and humiliated by the job, he
was complaining one evening to Singh, telling him how he dreamt of
becoming chief photographer in a magazine, when someone from the table
next door tapped him on the shoulder. It was the opportunity Gatha had
dreamed of, and his first fashion spread in Eve’s Weekly made the magazine
sell out.
New York still beckoned and Gatha took the plunge and flew to the
golden apple with eight dollars and a return ticket in his bags. However,
Gatha’s luck travelled with him on the plane to New York where he sat next to
an art director, Toni Palladino, who gave him his footstep to international
fame.
Within a week of arriving in New York, Gatha had completed the “Daily
News” campaign and earned himself $11,000. The tobacco industry turned its
expert eye on Gatha and throughout the 70s and 80s, Gatha developed
images to help sell cigarettes. “The only thing I can say, today,” says Gatha in
defence, “is that not once did I develop a campaign targeting teenagers or
children. That always remained a moral principle. As adults we can choose
what we do with our bodies and our lives, but youngsters must be protected.”
Gatha has seen the innards of the tobacco industry, including visiting
factories and production centres normally out of bounds. “The most shocking
experience was in a tobacco plant in Pakistan, near Peshawar - the place was
thick with tobacco dust. The ventilation was installed but did not work. The
poor workers had no protection and wore only cloth rags. I was sick as a dog
and had to rush out to vomit,” Gatha says.
So why did Ashvin Gatha quit smoking and change sides? “I was in the
Far East in 1991. Smoking about two packs a day and walking down these
polluted streets with carbon monoxide, lead and filth and I thought to myselfI don’t need to poison myself anymore. So on August 1, the date that the
Swiss confederation was founded, I quit. From two packs to zero.”
The “quitting” didn’t stop there. Gatha then began to reflect on what
cigarettes actually are, how they work and how they are sold. “In today’s
society we are bombarded by the media, not given time to think for ourselves.
Cigarettes are like a drug, a hypodermic needle and are a defiance of
individual freedom. We purchase the dreams that the cigarette companies
churn out. Never mind that we are killing ourselves in the process,” sighs
Gatha.
This is the year that WHO’s campaign on cessation succinctly summed
up by Gatha through his orchid and the ashtray image will encourage people
to “leave the pack behind.”
For further information, journalists can contact WHO’s Office of Public Information, Geneva.
Telephone (41 22) 791 2584. Fax (41 22) 791 4858. E-Mail: info@who.ch
All WHO Press Releases, Fact Sheets and Features as well as other information on
this subject can be obtained on Internet on the WHO home page http://www.who.ch/
World Health Organization
Tobacco Free Initiative
The FCTC is no ordinary convention -It is potentially a Public Health Movement
The spectacular rise and spread of tobacco consumption around the world is a challenge and
an opportunity for the World Health Organization. The challenge comes in seeking global
solutions for a problem that cuts across national boundaries, cultures, societies and socio
economic strata. The unique and massive public health impact of tobacco provides the WHO
an opportunity to propose to the world a first comprehensive response to deal with the silent
epidemic as the tobacco menace has often been called. The Tobacco Free Initiative (TFI) has
begun preliminary work in this direction.
The FCTC’s benefits to countries are many. The most significant one is that with the
Convention as a pathfinder and coordination vehicle, national public health policies, tailored
around national needs, can be advanced without the risk of being undone by transnational
phenomena (e.g. smuggling).
While framework conventions obligate States to cooperate in key areas, the process also
serves to forge important links between countries and other potential partners. Countries can
participate in the central framework while still deferring a decision on whether to participate
in protocols.
Framework Convention on Tobacco Control (FCTC) - A Primer
1. What is the FCTC?
The Framework Convention on Tobacco Control (FCTC) will be an international legal
instrument that will circumscribe the global spread of tobacco and tobacco products. This is
the first time that the WHO has activated Article 19 of its constitution, which allows the
Organization to develop and adopt such a Convention. In fact, the FCTC negotiations and
the adoption of the Convention should be seen as a process and a product in service of
public health.
This instrument will be developed by WHO’s 191 Member States so that their concerns are
adequately reflected throughout the process. In fact, the framework convention/protocol
approach will allow Member States to proceed with the process of crafting this piece of
international legislation in incremental stages:
• The Framework Convention will establish the legal parameters and structures of the
public health tool. It’s a little like laying the foundation of a building.
•
The Protocols will be separate agreements that will make up the substantive part of the
agreement - building on the foundation.
2. When will it be completed?
Executive Board Resolution 103.R11 maps out a process for developing the WHO FCTC and
possible related protocols. This process, which will be considered by the World Health
Assembly in May 1999, foresees the adoption of the Framework Convention and possible
related protocols by the World Health Assembly no later than May 2003. Each negotiating
process is unique and has its own momentum. The FCTC can be completed earlier if WHO’s
Member States so decide. Much depends on political will and a sustained commitment to the
cause of public health. One option would be to negotiate one or more protocols
simultaneously with the Framework Convention.
In one case, for example, three Protocols were negotiated along with the main body of the
Framework Convention1.
3. How will the FCTC help international tobacco control?
I. The FCTC and related protocols will improve transnational tobacco control and
cooperation through the following avenues:
• The guiding principles of the Convention could encompass both national and
transnational measures making it clear that: tobacco is an important contributor to
inequity in health in all societies; as a result of the addictive nature and health damage
associated with tobacco use it must be considered as a harmful commodity; the public
has a right to be fully informed about the health consequences of using tobacco products;
and the health sector has a leading responsibility to combat the tobacco epidemic, but
success cannot be achieved without the full contribution of all sectors of society.
• Under the Convention, State Parties would take appropriate measures to fulfil, through
coordinated actions, the general objectives which they had jointly agreed to. In this
respect, the FCTC could include the following general objectives: protecting children
and adolescents from exposure to and use of tobacco products and their promotion;
preventing and treating tobacco dependence; promoting smoke-free environments;
promoting healthy tobacco-free economies, especially stopping smuggling; strengthening
women’s leadership role in tobacco control; enhancing the capacity of all Member States
in tobacco control and improving knowledge and exchange of information at national
and international levels; and protecting vulnerable communities, including indigenous
peoples.
•
The protocols could include specific obligations to address inter alia: prices, smuggling,
tax-free tobacco products, advertising/sponsorships, Internet advertising/trade, testing
methods, package design/labeling, information sharing, and agricultural diversification.
Unless national and transnational dimensions of tobacco control are addressed in tandem,
even the best comprehensive national control programs can be undone. The national and
global thrusts of the Convention, by the way, are interdependent.
II. The process of developing and adopting the FCTC and related protocols will also help to:
mobilize national and global technical and financial support for tobacco control; raise
awareness among several ministries likely to come into the loop of global tobacco
control, as well as various sectors of society directly concerned with the public health
aspects of tobacco; strengthen national legislation and action; and mobilize NGOs and
other members of civil society in support of tobacco control.
In the run-up to the adoption of the FCTC, the WHO and its Regional Offices will work with
NGO’s, media and civil society in countries to focus on tobacco in all its dimensions.
1 Reference is made to the “Convention on the prohibition and restrictions on the use of certain conventional
weapons which may be deemed to be excessively injurious or to have indiscriminate effects" (1980).
2
4. What is the difference between a treaty, a convention, a protocol and a
resolution?
• A treaty is an international legal agreement concluded between States in
written form, and governed by international law;
• A convention (and also a framework convention) is a different name for a
treaty;
• A protocol is also a form of treaty. It typically supplements, clarifies, amends
or qualifies an existing international agreement, for example, a framework
convention;
• A resolution is an expression of common interest of numerous states in
specific areas of international cooperation.
5. Which of the above is legally binding?
Treaties are legally binding. The framework convention usually entails more general or
limited obligations, while the protocols involve more specific legal obligations.
A resolution is non-binding and does not normally entail any substantive commitments of a
legal nature.
6. In this case wouldn’t a resolution suffice?
A resolution is not sufficient to deal effectively with the public health threats associated with
the tobacco trade, its marketing, and use. Over the past 25 years, the World Health Assembly
has adopted 16 resolutions on several aspects of tobacco control with varying degrees of
success. Some Member States have sharpened these resolutions domestically giving them
more focus and bite. This piece-meal approach, however, is too informal to be of any major
consequence, especially for tobacco control where the international dimension of the problem
has a direct bearing on how the issue is addressed domestically. However, resolutions
adopted in other international fora will undoubtedly support and act as a catalyst for the
FCTC process.
The Framework Convention is about tobacco control in the long run. The FCTC’s principal
advantage is that it will allow the WHO and its extended family - which includes individual
countries and individuals in countries - to reap the public health benefits resulting from the
control of tobacco and its spread through society. This is a legal instrument in service of
health.
7. What happened to the process started in 1996? Wasn’t there a work plan then?
In May 1996, the World Health Assembly adopted WHA Res. 49.17 calling upon the
Director-General of WHO “to initiate the development of a Framework Convention in
accordance with Article 19 of the WHO Constitution.” This was the first time the WHO was
activating its constitutional mandate (Article 19) to develop a convention. There were no
precedents for developing a detailed work plan. Between 1996-1998 some preparatory
technical work was undertaken, but no detailed work plan was agreed to. As part of that
work, a preliminary timetable was circulated during the 51st World Health Assembly in May
1998. The Tobacco Free Initiative took the relevant parts of that initial process into
consideration before developing this detailed work plan which reflects the political and
technical requirements for negotiating the FCTC.
3
8. The WHO already has a mandate to commence negotiations. Why are you seeking it
again?
WHA Res. 49.17 gives the Director-General a mandate to start work on developing a
Framework Convention in accordance with Article 19, but DOES NOT provide a mandate to
the Director-General to commence negotiations. The FCTC negotiation is a prerogative of
sovereign States, and requires the establishment of a formal negotiating body. Only the
World Health Assembly has the legal authority to launch the negotiating process. The
accelerated work plan and the draft resolution proposed by the Secretariat suggests that an
Intergovernmental Negotiating Committee be established by the Assembly to proceed with
formal negotiations. The role of the WHO Secretariat in this process is to provide technical
support and advice to Member States in the negotiation of the FCTC and related protocols.
9. What are the roles of the FCTC Working Group and the Intergovernmental
Negotiating Body?
Executive Board Resolution EB103.R11, which describes the FCTC Working Group and
Intergovernmental Negotiating Body, maps out an integrated process for developing the
FCTC and possible related protocols with the full participation of Member States. During the
May 1999 World Health Assembly, Member States will be asked to establish both a FCTC
Working Group and an Intergovernmental Negotiating Body. The mission of the proposed
FCTC Working Group, which will be open to all Member States, will be to prepare proposed
draft elements of the FCTC and to submit a report to the Fifty-Third World Health Assembly.
Formal negotiations will commence with the convening of the first meeting of the proposed
Intergovernmental Negotiating Body by the Director General, which is expected to occur in
May 2000. The Intergovernmental Negotiating Body, which will be open to all Member
States, will be charged with the responsibility of negotiating the text of the Convention and
possible related protocols.
10. Who is going to pay for the FCTC?
The budget for the FCTC will, initially, need to be financed through extra-budgetary funding.
These costs will include WHO technical support, support for intergovernmental technical and
negotiation meetings, and support for the establishment of FCTC national commissions to
provide support for the process within countries. In the medium to long-term regular budget
funds will be required to ensure sustained implementation.
In particular, developing countries will require financial and technical assistance to
participate in the process of formulating the FCTC. In this regard, the recent technical
consultation in Vancouver recommended that WHO establish a separate Trust Fund for this
purpose.
Resources will also be required during the implementation phase. Funds will be necessary to
help countries build capacity and participate in global and national tobacco control activities.
In this respect, provision should be made in the FCTC for the establishment of a Multilateral
Trust Fund, with contributions from governments, international agencies, and private sources.
11. Will resources from on-going tobacco control be diverted to the FCTC process?
New extra-budgetary funds will need to be committed to the FCTC process, but no
previously allocated funds for tobacco control will be diverted to support the FCTC process.
Support to the FCTC should be seen as an integral part of supporting national and global
tobacco control. In reality, the successful adoption of the FCTC will likely result in a marked
increase in financial resources for tobacco control both within countries and at the
4
international level. The FCTC, when adopted, will ensure that tobacco control is given a
higher political profile. The adoption of the FCTC represents a barometer of success or
failure in placing tobacco control front and centre on the global stage.
The environmental movement has been successful in having numerous multilateral binding
agreements adopted at the international level, and as part of some of these agreements, for
example the 1987 Montreal Protocol on Substances that Deplete the Ozone Layer, significant
financial resources have been made available to assist developing countries. Similarly, the
FCTC could facilitate global cooperative actions, including the flow of additional financial
resources.
12. What will happen to economies that depend on tobacco?
The widely held perception that tobacco control will lead to loss of revenues is really a
perception! In reality, the numbers are heavily in favor of moving away from tobacco
cultivation. Recent economic analyses, for example World Bank data to be published this
year, as well as the publication, “The Economics of Tobacco Control: Towards an optimal
policy mix ”, show that the social and health costs of tobacco far outweigh the direct
economic benefits that may be possible because of tobacco cultivation.
The tobacco industry relies on the argument that there are no real crop or other substitution
options. It is reasonable to assume that consumers who stop smoking will reallocate their
tobacco expenditure to other goods and services in the economy. Therefore, falling
employment in the tobacco industry will be offset by increases in employment in other
industries. However, in the short-term, for countries which rely heavily on tobacco exports
(i.e. the economy is a net exporter of tobacco), economic/ agricultural diversification will
likely entail employment losses.
The FCTC takes a long-term view of agricultural diversification. The framework-protocol
approach provides for an evolutionary approach to developing an international legal regime
for tobacco control, and thus all issues will not need to be addressed at the same time.
Further, the need for a multilateral fund to assist those countries which will bear the highest
adjustment cost needs to be established. The FCTC will probably be the first instrument
seeking global support for tobacco farmers.
Also, it is worth noting that the current 1.1 billion smokers in the world are predicted to rise
to 1.64 billion by 2025, mainly due to population increases in developing countries.
Therefore, tobacco growing countries are extremely unlikely to suffer economically from any
tobacco control measures such as the FCTC.
13. Which ministries are expected to be involved in the negotiations?
In addition to the leading role of the Ministries of Health, Ministries of Foreign Affairs
typically take a lead role in the negotiation of conventions/treaties. Ministries of Finance,
Environment, Labour, Justice, Foreign Trade, Education and Agriculture will also be
expected to come into the ambit of the negotiations at some point.
14. Do internationally binding conventions/treaties lead to action and tangible results?
Adopting an international agreement can make a significant difference. For example:
5
•
Production and consumption of substances that deplete the stratospheric ozone layer
have declined dramatically over the last decade, as a result of the Montreal Ozone
Protocol.
•
The General Agreement on Tariffs and Trade has brought down trade barriers and
promoted the expansion of international trade.
•
Arms control agreements have limited nuclear weapons proliferation and have led to a
substantial reduction in the arsenals of the nuclear powers.
Can international agreements affect the behaviour of States? In some cases, international
agreements establish meaningful enforcement mechanisms, such as the World Trade
Organization’s dispute settlement system. But even in the absence of such mechanisms, an
international agreement can:
•
establish review mechanisms that focus pressure on States by holding them up to public
scrutiny;
•
articulate legal rules that may be enforceable in domestic courts;
•
provide supporters within national governments with additional leverage to pursue the
treaty’s goals.
Thus, while treaties rarely cause a state to immediately reverse its behaviour, they can
produce significant shifts in behaviour, both because they change a State’s calculation of
costs and benefits, and because most states feel that they ought to comply with their
promises.
15. Why should the FCTC be developed and negotiated under the auspices of the World
Health Organization, rather than, for example, under the umbrella of the United
Nations?
The World Health Organization is the only international multilateral organization that brings
together the technical and public health expertise necessary to serve as a platform for the
negotiation and effective implementation of the Framework Convention on Tobacco Control.
Although the United Nations also has the legal authority to sponsor the creation of
international instruments on tobacco control, the UN has neither the specialized
technical expertise nor, perhaps, the time to engage in negotiating complex standards on
tobacco control, particularly if extensive negotiation of the Convention is required.
Complex technical standards on tobacco control should be established and monitored by
WHO, the primary specialized agency in public health. In WHA 49.17 Member States
recognized the unique capacity of WHO to serve as a platform for the adoption of the FCTC
by calling upon the Organization to initiate the development of the Convention.
However, in so far as the ultimate goal of global tobacco control may require the regulation
of areas falling within the mandate of other United Nations’ Bodies establishment of a joint
negotiating mechanism, especially with regard to possible specialized protocols, could be
considered as an option.
6
16. What linkages will the work on the FCTC have with other regional /international
agreements, which could have added value for the FCTC?
Under the WHO/UNICEF project, "Building alliances and taking action to create a
generation of tobacco-free children and youth, supported by the United Nations Foundation,
a review of the Convention on the Rights of the Child with respect to tobacco control, is
currently being conducted. Also, with respect to TFI’s work on strengthening the role of
women in global tobacco control, possible links between the FCTC and the United Nation’s
Convention on the Elimination of all Forms of Discrimination Against Women (CEDAW),
will be considered. Links between the FCTC and other international treaties addressing
issues such as smuggling will also be examined. Furthermore, all efforts will be made to
build on proposed and existing regional tobacco control agreements.
i
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7
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WORLD
HEALTH
ORGANIZATION
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REGIONAL
OFFICE
SOUTH - EAST
FOR
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REGIONAL COMMITTEE
Provisional Agenda item 8.1
Fifty-second session
SEA/RC52/12
5 September 1999
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RECOMMENDATIONS
ARISING OUT OF THE TECHNICAL DISCUSSIONS
ON TOBACCO OR HEALTH: ACTIONS FOR 21st CENTURY
SEA/RC52/12
CONTENTS
1.
INTRODUCTION
1
1.1
Opening Remarks by the Director, Department of
General Management, WHO/SEARO..................
1
1.2
Introductory Remarks by the Chairman
1
1.3
Presentation by Dr (Ms) Martha Osei, Regional Adviser
on Health Promotion and Education, WHO/SEARO......
1
2.
DISCUSSIONS
3
3.
RECOMMENDATIONS
6
SEA/RC52/12
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1.
INTRODUCTION
The Technical Discussions on Tobacco or Health: Actions for the 21st Century were
held on 2 September 1999 under the Chairmanship of Dr Suwit Wibulpolprasert,
Assistant Permanent Secretary for Public Health, Ministry of Public Health, Thailand.
Dr H.A.P. Kahandaliyanage, Senior Assistant Secretary, Ministry of Health and
Indigenous Medicine, Sri Lanka, was elected Rapporteur. During the absence of Dr
Suwit, Ms Sujatha Rao, Joint Secretary, Ministry of Health and Family Welfare,
Government of India, chaired the discussions. The agenda and annotated agenda
(SEA/PDM/Meet.36/9.1.1 and SEA/PDM/Meet.36/9.1.1 Add.1) and the working
paper for the Technical Discussions (SEA/PDM/Meet.36/9.1.2) formed the basis for
the discussions.
1.1
Opening Remarks by the Director, Department of General Management,
WHO/SEARO
Mr R. Spina Helmholz said that the global increase in tobacco consumption,
particularly in the developing world, presented a major public health concern,
considering the heavy disease and economic burden in the Region. Taking
cognizance of the serious health implications of the use of tobacco, the 51st session
of the Regional Committee selected this subject for Technical Discussions with a
view to define a focussed and collective direction for tobacco control in the Region.
Mr Helmholz expressed the hope that the recommendations of the Technical
Discussions, duly endorsed by the Regional Committee, would guide the Member
States in employing a multi-pronged strategy for tobacco control in the Region.
1.2
Introductory Remarks by the Chairman
In his opening remarks, Dr Suwit Wibulpolprasert said that tobacco use posed one of
the greatest public health challenges globally. However, it was heartening to note
that some countries in the Region had addressed the tobacco-related issues facing
them effectively and made significant progress in containing this 20th-century
scourge. He stressed that strong political will, legislation, a complete ban on tobacco
advertising and social mobilization among the tobacco users could be important
ways in which the increase in tobacco consumption could be arrested.
1.3
Presentation by Dr (Ms) Martha Osei, Regional Adviser on Health
Promotion and Education, WHO/SEARO
Ms Martha Osei, Regional Adviser on Health Promotion and Education, presented
the working paper and introduced the subject. She said that the objectives of the
discussions were to review the global and regional situation and to develop
strategies for action in the 21st century. She recalled the various resolutions adopted
by the World Health Assembly towards comprehensive strategies for tobacco
control. Between 1970 and 1988, a total of 17 resolutions were adopted, all stressing
SEA/RC52/12
Page 2
effective control measures. But tobacco consumption had been on the increase,
particularly in developing countries. Against this background, the World Health
Assembly requested the Director-General to develop a Framework Convention in
Tobacco Control, which would be a global, legally binding instrument.
The WHO cabinet project on Tobacco Free Initiative, launched in July 1998, had
adopted a fast track approach towards the development of this Framework. The
recently adopted World Health Assembly resolution WHA 52.18 provided clear
guidance on the process of the development and negotiation of the Framework
Convention and related protocols.
Tobacco Use: Implications for Global Public Health
On tobacco production and trade, she noted the steady increase since the 1900s,
particularly in developing countries. Eighty per cent of the tobacco consumed
globally was produced in developing countries. Currently several million metric
tonnes of tobacco was produced globally. Over the past decade, the share of global
production by high income countries had decreased from 30% to 15%, while that by
countries in the Middle East and Asia had risen from 40% to 60%. World wide
tobacco consumption was increasing by about 2% annually with the biggest rise
occurring in the developing countries and Eastern Europe. Of the 1.2 billion smokers
globally, 800 million lived in developing countries. Tobacco killed 3.5 million people
every year. By 2030, this would rise to 10 million, with 7 million deaths occurring in
developing countries. The shift of the tobacco epidemic to the developing countries
was obvious.
Tobacco use among women was also known to cause stillbirths, low birth weight and
perinatal deaths. The linkages between tuberculosis and smoking had also been
documented, with smokers infected with tuberculosis facing a greater risk of death
from tobacco-related diseases than their non-smoking counterparts. Tobacco also
caused considerable economic loss for all countries. Currently, the world loses
US$200 billion a year with one-third of the loss being borne by developing countries.
The impact of tobacco on the environmental sustainability was also significant.
Tobacco-related morbidity and mortality
In the South-East Asia Region, there had been a steady increase in the production
and consumption of tobacco in both its smoking and smokeless forms across all
sections of population groups, particularly among women, children and the poor.
Tobacco products in the Region contained higher levels of nicotine and tar compared
with the levels in developed countries.
Cancers, cardiovascular diseases and emphysema were increasing, as major killers
in some countries of the Region. Low literacy, high poverty levels and lack of
adequate public awareness of the hazards of tobacco, presented a favourable
environment for a possible tobacco epidemic in the Region. Effective action to
control tobacco was therefore urgently needed.
SEA/RC52/12
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Controlling Tobacco Use in the Region
It was noted that an effective balance was needed between opportunities and
challenges in the Member Countries, to achieve comprehensive tobacco control.
Opportunities such as existing components of national control strategies,
documented, effective and proven strategies and the current global movement for
tobacco control would need to be maximized to achieve the desired level of
reduction in tobacco consumption in the Region. But the challenges of the perceived
economic value of tobacco, the huge pool of potential smokers being targetted by
the tobacco industry advertisements, the lowering of the age of initiation, lack of
awareness of tobacco hazards and the steady shift of the tobacco industry into the
Region, should be recognized.
Significant action had been taken in most countries of the Region to tackle the
menace of tobacco. A partial ban on advertisements, establishment of non-smoking
islands and districts in some countries, non-smoking flights, a ban on smoking in
public places were some of them. However, additional efforts and resources were
urgently needed in a concerted manner and on multiple fronts.
Several legislative measures, such as comprehensive ban on advertisements of
tobacco products, restriction of access to tobacco products by minors in schools,
restriction on smoking at workplaces and public areas to protect people from the
effects of environmental tobacco smoke, compulsory disclosure of ingredients
including nicotine levels in cigarettes and highly visible warnings on cigarette packets
and cartons could be undertaken. Increase in the real price of tobacco products to
reduce consumption and make it unaffordable for poor consumers and, at the same
time, increase government revenue, was an effective weapon for tobacco control.
Making Tobacco Control a reality
Tobacco should be a priority item on the political and development agenda of
countries. The leadership role of the ministries of health cannot be overemphasized
for advocacy and intensified political commitment for the participation of other
sectors. A network of NGOs, institutes of excellence, training colleges, the primaiy
health care infrastructure and poverty alleviation programmes could work in
partnership with each other. Research and surveillance tended to be weak and data
was hard to come by. These need to be strengthened to support tobacco control
measures and to provide basic information and evidence for advocacy and policymaking. Mobilization of communities and civil society was critical for effective
tobacco control measures.
2.
DISCUSSIONS
The Regional Policy Framework for Tobacco Control and the Action Plan
2000-2004 developed at a Regional consultation to provide collective direction
for tobacco control should be proposed for adoption by the Regional
Committee for implementation by Member Countries. These documents were
endorsed by the group.
SEA/RC52/12
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Political commitment and conviction were essential for the success of the
tobacco control initiatives in the countries. It had been demonstrated that public
concern motivated strong political will resulting in significant progress in
tobacco control measures as in Sri Lanka and Thailand.
The necessity for countries to have focal points for tobacco control activities
was emphasized. It was, however, preferable to have a network of several
institutions or focal points, as individuals could always become vulnerable to the
manipulations of multinational cigarette companies.
The most important strategies for tobacco control were: taxation, legislation,
regulation and education with the emphasis on social mobilization.
Some of the myths and beliefs associated with smoking in the rural, hilly areas
of Nepal were that it helped to keep users warm and provided energy in the
cold weather. In the urban areas, cigarettes were associated with better self
image, stress relief and a sense of belonging to peer groups.
The possibilities of involving different sections of society in tobacco control such
as teachers, community leaders, religious leaders, NGOs, and role models
such as sports personalities, film stars and models should be explored. The
involvement of NGOs in imparting suitable training to opinion leaders in the
community should be encouraged.
Insufficient information and data on the ill effects of smoking was one of the
reasons for the low effectiveness of advocacy programmes. Meanwhile,
information and documents on the strategies adopted by the multinational
tobacco companies to promote sales of tobacco were becoming available;
these should be used to strengthen advocacy and education for tobacco
control.
Tobacco companies marketed their products aggressively with huge budgets
for sophisticated advertising campaigns. On the other hand, the health
ministries had scarce resources and were therefore unable to counter these
campaigns.
Some countries had achieved a breakthrough in tobacco control through a
complete ban on advertising of tobacco products and alcohol on national
television. These efforts were, however, getting diluted by advertisements of
tobacco products on some foreign channels, cable television networks and the
foreign print media. It was extremely difficult to regulate such advertising for
want of international protocols. This was an area that WHO needed to focus on
as it was beyond the control of any single country.
Since there were substantial numbers of potential smokers in the school-going
and adolescent age groups, it was necessary to include strong messages
against smoking and tobacco use in the school health education curriculum.
SEA/RC52/12
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Media involvement and support in countering tobacco advertisements by
highlighting the adverse cosmetic effects of smoking on the health and
personality of the smoker could be explored.
Youth and adolescents could be reached through mass rallies, campaigns
etc. They could be motivated to advocate on behalf of tobacco control with
senior government leaders.
The countries of the Region faced a heavy disease burden and had very
scarce resources to combat a wide spectrum of communicable and
noncommunicable diseases. As such, it was difficult to allocate adequate
funds for tobacco control to make a difference. However, the use of mass
media, pamphlets, booklets, and handbills etc. should be encouraged to
convey ihe message that Tobacco kills, to the large populations in the
countries of the Region.
While several countries earned substantial revenues from tobacco taxation
and excise duties, there was no policy to earmark any proportion of these
revenues for tobacco control activities. However, it was seen that in some
countries such as Thailand and Nepal, a percentage of the revenue earned
was utilized to sustain the tobacco control programme. WHO should strongly
urge all Member States to allocate a portion of the revenue earned from
tobacco advertising and taxation for tobacco control programmes.
It had been established that tobacco caused impotence and sub-fertility. This
message could be used as an effective counter-measure to combat tobacco
advertising.
WHO could encourage the medical community and health professionals to
eschew the use of tobacco to set an example as role models for the
community.
Different approaches for reaching illiterate populations could be attempted.
Especially in the rural areas, where there is no electronic media, puppet
shows, radio talks, folk theatre and pop songs could be effective tools to be
considered.
Mere control of tobacco consumption might not yield the desired results. The
most important and sustainable measure was the ‘social vaccine injection
through intensive education to women and children. Through partnership
among various sections of society, some measure of success could be
achieved.
Focused research on the prevalence, causes and effects of tobacco
consumption and research related to effective strategies to reduce prevalence
among adolescents, women and the poor should be undertaken.
SEA/RC52/12
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There was need for solidarity among Member Countries for exchange of
information and experiences on tobacco-related issues.
While strict rules were in force for food additives and flavours, there was no
regulation for the manufacture of cigarettes. It was now recognized that
product regulation could be a key approach for control of tobacco.
Governments faced difficulty in enforcing tobacco regulations due to crossborder smuggling of tobacco products.
Due to a fall in tobacco consumption in the developed countries, there was
increasing pressure from western countries to dump tobacco products in the
developing world.
Teachings in various religions were a powerful tool to advocate rejection of
tobacco consumption. Religious bodies and leaders could be mobilized for
educating the people in the community regarding the ill effects of tobacco use.
Fires caused by smouldering cigarette butts had resulted in heavy economic
losses in Bangladesh.
WHO/HQ should take up the issues and regulations on advertising and media
coverage with the international media, with WTO regarding dumping and the
right of countries to impose non-tariff barriers on tobacco trading and the
development of media materials for wide dissemination.
WHO should focus more on support to country efforts to establish cessation
services and less on holding consultations or meetings.
WHO/HQ should also allocate adequate resources for tobacco control.
Currently, the budget is hardly US$2 million as compared to US$1000 million
allocated to Roll-Back Malaria.
3.
RECOMMENDATIONS
1.
The members of the Technical Discussions group should adopt the document
on ‘Policy Framework for Tobacco Control and Action Plan for 2000-2004’ and
forward it to the Regional Director for adoption by the Regional Committee.
2.
Each Member Country should constitute a national council for tobacco control
with representation from government, nongovernmental organizations,
tobacco control experts etc. and also take steps to develop the capacity of a
network of institutions on different aspects of tobacco control.
3.
Member Countries should initiate action to develop more comprehensive
country-specific strategies for tobacco control.
SEA/RC52/12
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4.
Member Countries should initiate action to enact strong legislation, increase
taxation on tobacco products, institute regulations and impart education on
the ill effects of tobacco use.
5.
Focused research on the prevalence, causes and effects of tobacco
consumption and research related to effective strategies to reduce prevalence
among adolescents, women and the poor should be undertaken.
6.
Nicotine should be regulated as a drug and governments should establish a
mechanism to monitor its use.
7.
Strong messages about the ill effects of smoking and tobacco use should be
included in the school curriculum for adolescents.
8.
WHO should adopt a strongly worded resolution urging all Member States to
set apart a portion of the money earned from tobacco advertising and taxation
for tobacco control programmes.
9.
WHO should provide all available information and data on the adverse effects
of tobacco on health and the long-term economic implications of tobacco use
to the political leadership in the Region for policy formulation.
10.
WHO should advocate tobacco control measures in collaboration with WTO
for regulation of tobacco trade.
11.
WHO should encourage medical associations and health professionals to
lead, by example, by eschewing tobacco use themselves.
National
governments should give preference on recruitment to non-smokers for
positions in government service.
12.
WHO/HQ should allocate adequate resources for tobacco control activities.
WHO/NCD/TFI/99.9
Original: English
Distr.: General
Statement on Treatment for
Tobatto Dependente
i
World Health Organization
Tobacco Free Initiative
2 Statement on Treatment for Tobacco Dependence
The worldwide epidemic of tobacco-related disease and death continues to
worsen as tobacco use spreads. Millions of lives could be saved with
effective treatment for tobacco dependence. However, such treatment is
currently unavailable for many tobacco users throughout the world. For
this reason, the World Health Organization, in preparation for World No
Tobacco Day 1999 (31 May), offers the following information and
recommendations to governments, organizations, health-care
professionals, and tobacco users and nonusers worldwide.
About Tobafto and Treatment
Tobacco products are highly
addictive.
Tobatco use is widespread.
At the beginning of this decade at least one-third
ofthe global adult population, or 1.1 billion
people, used tobacco. Although overall tobacco
use is decreased in many developed countries, it
increased in most developing countries. An
estimated 48% of men and 7% of women in
developing countries smoked; in industrialized
countries, 42% of men and 24% of women
smoked, representing a marked increase among
women. Tobacco use is a pediatric epidemic, as
well. Most tobacco use starts during childhood
and adolescence.
Tobatto kills.
A long-term tobacco user has a 50% chance
of dying prematurely from tobacco-related
disease. Each year, tobacco causes some 4
million premature deaths, with 1 million of
these occurring in countries that can least
afford the health-care burden. This epidemic
is predicted to kill 250 million children and
adolescents who are alive today, a third of
whom live in developing countries. By the
year 2030, tobacco will be the world’s leading
cause of death and disability, killing more than
10 million people annually and claiming more
lives than HIV, tuberculosis, maternal
mortality, motor vehicle accidents, suicide, and
homicide combined.
Because tobacco products are carefully
designed to undermine efforts to quit using them,
quitting is not simply a matter of choice for the
majority of tobacco users. Instead, it involves a
struggle to overcome an addiction. Tobacco use
typically is woven into everyday life, and can be
physiologically, psychologically, and socially
reinforcing. Many factors combine with
tobacco’s addictive capacity to make quitting
difficult, including media depictions and cultural
and societal acceptance of tobacco use.
Quitting tobatto at any point in
life provides both immediate
benefits and substantial long-term
benefits to health.
No amount of tobacco use is safe. Abstinence
from tobacco products and freedom from
exposure to secondhand smoke are necessary
for maximizing health and minimizing risk.
Effective treatment for tobacco dependence can
significantly improve overall public health within
only a few years.
The currently available, proven
treatment methods work.
Hundreds of controlled scientific studies have
demonstrated that treatment can help tobacco
Statement on Treatment for Tobacco Dependence 3
users achieve permanent abstinence. Effective
treatment can involve a variety of methods, such
as a combination of behavioural treatment and
pharmacotherapy (nicotine replacement and non
nicotine medications). Population-based methods
such as telephone help-lines and national and
international tobacco-free days also can help
deliver treatment.
Implementing Treatment
1. Make Treatment a Priority.
Governments should rank treatment as an
important public-health priority.
2. Make Treatment Available.
Health-care systems should offer practical
interventions to all tobacco users, regardless of
economic level, age, and sex. This effort
includes preventing and treating tobacco use in
children and adolescents, reducing family
exposure to tobacco, and providing treatment
medications when appropriate. This process is
facilitated by incorporating tobacco dependence
treatment into drug abuse treatment, reproductive
and maternal-child services, and other programmes.
3. Assess Tobacco Use and Offer
Treatment.
Health-care providers should assess and docu
ment tobacco use and should provide treatment
as an essential part of quality total health care.
Health-care providers should assume
responsibility for learning about tobacco use and
treatment, and for providing proven interventions.
Providers, educators, and community leaders
should take advantage of teachable moments and
opportunities for prevention and intervention.
4. Health-care professionals should
set an example for their peers and
patients by quitting tobacco use.
Governments and education systems can help
this process by funding treatment and
education programs for health professionals in
training.
5. Fund Effective Treatment.
Governments and health care organizations
should fund treatment based on methods that
have been demonstrated to be effective, and
should make treatment widely available.
Increasing the institutional and human capacity
for providing this service involves training health
care workers to deliver treatment, implementing a
curriculum for students in the health professions,
developing resource centres, encouraging the
creation and maintenance of centres of
excellence in treating tobacco dependence, and
reducing the barriers between tobacco users and
treatment.
6. Motivate Tobacco Users.
Governments, health providers, and community
groups share a responsibility for motivating
tobacco users to quit and remain abstinent. They
should educate the public about the health risks of
tobacco use, encourage tobacco users to seek
treatment, and help make treatment available,
affordable, and accessible.
1. Monitor and Regulate Tobacco.
Governments should monitor and report on
tobacco use, and should tax and regulate the sale
and marketing of tobacco products. These
efforts reduce initiation of tobacco use and help
fund effective treatments. Responsible regulation
of tobacco products reduces tobacco use and
limits risk. Regulatory authorities should prohibit
marketing strategies that give false reassurances
about minimized health risks and divert attention
from quitting. Additionally, all possible steps
should be taken to reduce the harmfulness of
tobacco products. Governments should
collaborate to provide meaningful and accurate
ratings of nicotine and other chemicals in tobacco
products, and to reduce the toxicity and
addictiveness of those products. Treatment
medications should be at least as accessible as
tobacco products.
I
4 Statement on Treatment for Tobacco Dependence
8. Develop New Treatments.
Investing in the science and technology of
treatment improves the efficacy of treatment for
those in diverse populations and underserved
groups. Effective treatments should be
developed for groups for whom treatment has
not been available, such as children and
adolescents.
Universal application of all of these measures is
the most effective approach to tobacco
treatment. The current escalation in tobacco
use and in tobacco-related death and disease
can only be reversed by investment in
comprehensive tobacco control, which includes
treatment for tobacco dependence.
Governments, health-care systems, education
systems, community and religious groups, and
news and entertainment media should collaborate
in promoting tobacco treatment. World No
Tobacco Day on 31 May 1999, provides the
opportunity for governments, health-professional
bodies, and the media to join with WHO in
committing themselves to take local, national, and
global action that could bend the trend of the
tobacco epidemic.
(This statement, 'which is based upon the best
available scientific information, was 'written by
a group of experts from developed and
developing countries hosted by the Mayo
Clinic Nicotine Dependence Center and
prepared for WHO to disseminate worldwide
prior to 1999 World No-Tobacco Day A full
report will be available later in 1999; see
< www. who. org>.)
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The Tobacco Free Initiative is a new WHO
cabinet project created with the express aim of
focusing international attention and resources
on the global tobacco epidemic - the cause of a
vast and entirely avoidable burden of disease.
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WHO/NCD/TFI/99.8 Rev. 1
Original: English
Distr.: General
The Framework Convention
on Tobatto Control
A Primer
The FCTC is no ordinary convention.
It is potentially a Public Health
Movement
l/L
World Health Organization
Tobacco Free Initiative
2 IVHO Framework Convention on Tobacco Control
The spectacular rise and spread of tobacco consumption around the world
is a challenge and an opportunity for the World Health Organization. The
challenge comes in seeking global solutions for a problem that cuts across
national boundaries, cultures, societies and socio-economic strata. The
unique and massive public health impact of tobacco provides the WHO an
opportunity to propose to the world a first comprehensive response to deal
with the silent epidemic as the tobacco menace has often been called. The
Tobacco Free Initiative (TFI) has begun preliminary work in this direction.
On 24 May 1999, the World Health Assembly (WHA), the governing body
of the World Health Organization (WHO), paved the way for multilateral
negotiations to begin on a set of rules and regulations that will govern the
global rise and spread of tobacco and tobacco products in the next
century. The 191-member WHA unanimously backed a resolution calling
for work to begin on the Framework Convention on Tobacco Control
(FCTC) - a new legal instrument that could address issues as diverse as
tobacco advertising and promotion, agricultural diversification,
smuggling, taxes and subsidies. A record 50 nations took the floor to
pledge financial and political support for the Convention. The list
included the five permanent members of the United Nations Security
Council, major tobacco growers and exporters as well as several
countries in the developing and developed world which face the brunt of
the tobacco industry’s marketing and promotion pitch. The European
Union and 5 NGOs also made statements in support of the Convention
and the Director-General’s leadership in global tobacco control.
rTn he FCTC’s benefits to countries are
A many. The most significant one is that
with the Convention as a pathfinder and
coordination vehicle, national public health
policies, tailored around national needs, can
be advanced without the risk of being
undone by transnational phenomena (e g.
smuggling).
While framework conventions obligate
States to cooperate in key areas, the process
also serves to forge important links between
countries and other potential partners.
Countries can participate in the central
framework while still deferring a decision
on whether to participate in protocols.
Framework Convention on
Tobacto Control (FCTC) A Primer
1. What is the FCTC?
The Framework Convention on Tobacco Control
(FCTC) will be an international legal instrument
that will circumscribe the global spread of
tobacco and tobacco products. This is the first
time that the WHO has activated Article 19 of its
constitution, which allows the Organization to
develop and adopt such a Convention. In fact,
the FCTC negotiations and the adoption of
WHO Framework Convention on Tobacco Control 3
the Convention should be seen as a process
and a product in service of public health.
This instrument will be developed by WHO’s
191 Member States so that their concerns are
adequately reflected throughout the process. In
fact, the framework convention/protocol
approach will allow Member States to proceed
with the process of crafting this piece of
international legislation in incremental stages:
♦ The Framework Convention will establish the
legal parameters and structures of the public
health tool. It’s a little like laying the
foundation of a building.
♦ The Protocols will be separate agreements
that will make up the substantive part of the
agreement - building on the foundation.
2. When will it be lompleted ?
World Health Assembly Resolution WHA 52.18
maps out a process for developing the WHO
FCTC and possible related protocols. This
Resolution, which was adopted unanimously by
the World Health Assembly in May 1999,
foresees the adoption of the Framework
Convention and possible related protocols by
the World Health Assembly no later than May
2003. Each negotiating process is unique and
has its own momentum. The FCTC can be
completed earlier ifWHO’s Member States so
decide. Much depends on political will and a
sustained commitment to the cause of public
health. One option would be to negotiate one or
more protocols simultaneously with the
Framework Convention.
In one case, for example, three Protocols
were negotiated along with the main body of
the Framework Convention1.
1 Reference is made to the '‘Convention on the prohibition
and restrictions on the use ofcertain conventional
-weapons which may be deemed to be excessively injurious
or to have indiscriminate effect^ (1980).
3. How will the FCTC help
international tobatto tontrol ?
The FCTC and related protocols will improve
transnational tobacco control and cooperation
through the following avenues:
♦ The guiding principles ofthe Convention
could encompass both national and
transnational measures making it clear
that: tobacco is an important contributor to
inequity in health in all societies; as a
result of the addictive nature and health
damage associated with tobacco use it
must be considered as a harmful
commodity; the public has a right to be
fully informed about the health
consequences of using tobacco products;
and the health sector has a leading
responsibility to combat the tobacco
epidemic, but success cannot be achieved
without the full contribution of all sectors
of society.
♦ Under the Convention, State Parties, would
take appropriate measures to fulfil, through
coordinated actions, the general objectives
which they had jointly agreed to. In this
respect, the FCTC could include the
following general objectives, protecting
children and adolescents from exposure to
and use of tobacco products and their
promotion; preventing and treating tobacco
dependence; promoting smoke-free
environments; promoting healthy tobaccofree economies, especially stopping
smuggling; strengthening women’s leadership
role in tobacco control; enhancing the
capacity of all Member States in tobacco
control and improving knowledge and
exchange of information at national and
international levels; and protecting vulnerable
communities, including indigenous peoples.
♦ The protocols could include specific
obligations to address inter alia, prices,
4 WHO Framework Convention on Tobacco Control
4. What is the difference between a treaty, a convention, a protocol and a
resolution ?
♦ A treaty is an international legal agreement concluded between States in written form,
and governed by international law;
♦ A convention (and also a framework convention) is a different name for a treaty;
♦ A protocol is also a form of treaty. It typically supplements, clarifies, amends or
qualifies an existing international agreement, for example, a framework convention;
♦ A resolution is an expression of common interest of numerous states in specific areas
of international cooperation.
smuggling, tax-free tobacco products,
advertising/sponsorships, Internet
advertising/trade, testing methods, package
design/labeling, information sharing, and
agricultural diversification.
Unless national and transnational
dimensions of tobacco control are addressed
in tandem, even the best comprehensive
national control programs can be undone.
The national and global thrusts of the
Convention, by the way, are interdependent.
The process of developing and adopting the
FCTC and related protocols will also help
to: mobilize national and global technical
and financial support for tobacco control;
raise awareness among several ministries
likely to come into the loop of global
tobacco control, as well as various sectors of
society directly concerned with the public
health aspects of tobacco; strengthen
national legislation and action; and mobilize
NGOs and other members of civil society in
support of tobacco control.
In the run-up to the adoption of the FCTC,
the WHO and its Regional Offices will work
with NGO’s, media and civil society in
countries to focus on tobacco in all its
dimensions.
5. Which of the above is legally
binding ?
Treaties are legally binding. The framework
convention usually entails more general or
limited obligations, while the protocols
involve more specific legal obligations.
A resolution is non-binding and does not
normally entail any substantive commit
ments of a legal nature.
6. In this case wouldn't a resolution
suffice ?
A resolution is not sufficient to deal effectively
with the public health threats associated with
the tobacco trade, its marketing, and use. Over
the past 25 years, the World Health Assembly
has adopted 16 resolutions on several aspects
of tobacco control with varying degrees of
success. Some Member States have
sharpened these resolutions domestically giving
them more focus and bite. This piece-meal
approach, however, is too informal to be of any
major consequence, especially for tobacco
control where the international dimension ofthe
problem has a direct bearing on how the issue
is addressed domestically. However,
WHO Framework Convention on Tobacco Control 5
resolutions adopted in other international fora
will undoubtedly support and act as a catalyst
for the FCTC process.
The Framework Convention is about tobacco
control in the long run. The FCTC’s principal
advantage is that it will allow the WHO and its
extended family - which includes individual
countries and individuals in countries - to reap
the public health benefits resulting from the
control oftobacco and its spread through
society. This is a legal instrument in service
of health.
7. What happened to the process
started in 1996? Wasn't there a
work plan then ?
In May 1996, the World Health Assembly
adopted WHA Res. 49.17 calling upon the
Director-General ofWHO “to initiate the
development of a Framework Convention in
accordance with Article 19 of the WHO
Constitution.” This was the first time the WHO
was activating its constitutional mandate (Article
19) to develop a convention. There were no
precedents for developing a detailed work plan.
Between 1996-1998 some preparatory
technical work was undertaken, but no detailed
work plan was agreed to. As part of that
work, a preliminary timetable was circulated
during the 51 st World Health Assembly in May
1998. The Tobacco Free Initiative took the
relevant parts ofthat initial process into
consideration before developing this detailed
work plan which reflects the political and
technical requirements for negotiating the FCTC.
8. The WHO already has a mandate
to tommence negotiations. Why are
you seeking it again ?
WHA Res. 49.17 gives the Director-General a
mandate to start work on developing a
Framework Convention in accordance with
Article 19, but DOES NOT provide a
mandate to the Director-General to commence
negotiations. The FCTC negotiation is a
prerogative of sovereign States, and requires
the establishment of a formal negotiating body.
Only the World Health Assembly has the legal
authority to launch the negotiating process. The
accelerated work plan and the draft resolution
proposed by the Secretariat suggests that an
Intergovernmental Negotiating Committee be
established by the Assembly to proceed with
formal negotiations. The role ofthe WHO
Secretariat in this process is to provide technical
support and advice to Member States in the
negotiation ofthe FCTC and related protocols.
9. What are the roles of the FCTC
Working Group and the Intergovern
mental Negotiating Body ?
World Health Assembly Resolution WHA
52.18, which describes the FCTC Working
Group and Intergovernmental Negotiating
Body, maps out an integrated process for
developing the FCTC and possible related
protocols with the full participation of
Member States. During the May 1999 World
Health Assembly, Member States established
both a FCTC Working Group and an
Intergovernmental Negotiating Body. The
mission of the FCTC Working Group, which
will be open to participation by all WHO
Member States and regional economic
integration organizations, will be to prepare
proposed draft elements of the FCTC and to
submit a report to the Fifty-Third World
Health Assembly. The first meeting of the
FCTC Working Group is planned to take
place in Geneva, October 1999. Formal
negotiations will commence with the
convening of the first meeting of the
Intergovernmental Negotiating Body by the
Director-General, which is expected to occur
in May 2000. The Intergovernmental
Negotiating Body which will be open to
participation by all WHO Member States
6 WHO Framework Convention on Tobacco Control
and regional economic integration
organizations, will be charged with the
responsibility of negotiating the text of the
Convention and possible related protocols. In
addition, the States, organizations and entities
referred to in paragraph 3 (6) of Resolution
WHA 52.18 will be invited to participate as
observers in the FCTC Working Group and
the Intergovernmental Negotiating Body.
10. Who is going to pay for the FCTC ?
The budget for the FCTC will, initially, need to
be financed through extra-budgetary funding.
These costs will include WHO technical
support, support for intergovernmental technical
and negotiation meetings, and support for the
establishment of FCTC national commissions to
provide support for the process within countries.
In the medium to long-term regular budget funds
will be required to ensure sustained
implementation.
In particular, developing countries will require
financial and technical assistance to participate in
the process of formulating the FCTC. In this
regard, the recent technical consultation in
Vancouver recommended that WHO establish a
separate Trust Fund for this purpose.
Resources will also be required during the
implementation phase. Funds will be necessary
to help countries build capacity and participate
in global and national tobacco control activities.
In this respect, provision should be made in the
FCTC for the establishment of a Multilateral
Trust Fund, with contributions from governments,
international agencies, and private sources.
previously allocated funds for tobacco control
will be diverted to support the FCTC process.
Support to the FCTC should be seen as an
integral part of supporting national and global
tobacco control. In reality, the successful
adoption of the FCTC will likely result in a
marked increase in financial resources for
tobacco control both within countries and at the
international level. The FCTC, when adopted,
will ensure that tobacco control is given a higher
political profile. The adoption of the FCTC
represents a barometer of success or failure in
placing tobacco control front and centre on the
global stage.
The environmental movement has been
successful in having numerous multilateral
binding agreements adopted at the international
level, and as part of some ofthese agreements,
for example the 1987 Montreal Protocol on
Substances that Deplete the Ozone Layer,
significant financial resources have been made
available to assist developing countries.
Similarly, the FCTC could facilitate global
cooperative actions, including the flow of
additional financial resources.
12. What will happen to etonomies
that depend on tobatto ?
11. Will resources from on-going
tobacco control be diverted to the
FCTC process ?
The widely held perception that tobacco
control will lead to loss of revenues is really a
perception! In reality, the numbers are
heavily in favor of moving away from
tobacco cultivation. Recent economic
analyses, for example World Bank data to be
published this year, as well as the publication,
“The Economics of Tobacco Control:
Towards an optimal policy mix ”, show that
the social and health costs of tobacco far
outweigh the direct economic benefits that
may be possible because of tobacco
cultivation.
New extra-budgetary funds will need to be
committed to the FCTC process, but no
The tobacco industry relies on the argument
that there are no real crop or other
WHO Framework Convention on Tobacco Control
substitution options. It is reasonable to
assume that consumers who stop smoking
will reallocate their tobacco expenditure to
other goods and services in the economy.
Therefore, falling employment in the tobacco
industry will be offset by increases in
employment in other industries. However, in
the short-term, for countries which rely
heavily on tobacco exports (i.e. the economy
is a net exporter of tobacco), economic/
agricultural diversification will likely entail
employment losses.
The FCTC takes a long-term view of
agricultural diversification. The framework
protocol approach provides for an
evolutionary approach to developing an
international legal regime for tobacco control,
and thus all issues will not need to be
addressed at the same time. Further, the
need for a multilateral fund to assist those
countries which will bear the highest
adjustment cost needs to be established.
The FCTC will probably be the first
instrument seeking global support for
tobacco farmers.
Also, it is worth noting that the current 1.1
billion smokers in the world are predicted to
rise to 1.64 billion by 2025, mainly due to
population increases in developing countries.
Therefore, tobacco growing countries are
extremely unlikely to suffer economically
from any tobacco control measures such as
the FCTC.
13. Which ministries are expected
to be involved in the negotiations ?
In addition to the leading role of the Ministries
of Health, Ministries ofForeign Affairs typically
take a lead role in the negotiation of
conventions/treaties. Ministries ofFinance,
Environment, Labour, Justice, Foreign Trade,
Education and Agriculture will also be expected
to come into the ambit of the negotiations at
some point.
14. Do internationally binding
conventions/treaties lead to action
and tangible results ?
Adopting an international agreement can make
a significant difference. For example:
♦ Production and consumption of substances
that deplete the stratospheric ozone layer
have declined dramatically over the last
decade, as a result of the Montreal Ozone
Protocol.
♦ The General Agreement on Tariffs and
Trade has brought down trade barriers and
promoted the expansion of international
trade.
♦ Arms control agreements have limited
nuclear weapons proliferation and have
led to a substantial reduction in the
arsenals of the nuclear powers.
Can international agreements affect the
behaviour of States? In some cases,
international agreements establish
meaningful enforcement mechanisms, such
as the World Trade Organization’s dispute
settlement system. But even in the absence
of such mechanisms, an international
agreement can:
♦ establish review mechanisms that focus
pressure on States by holding them up to
public scrutiny;
♦ articulate legal rules that may be enforceable
in domestic courts;
♦ provide supporters within national
governments with additional leverage to
pursue the treaty’s goals.
Thus, while treaties rarely cause a state to
immediately reverse its behaviour, they can
produce significant shifts in behaviour, both
because they change a State’s calculation of
costs and benefits, and because most states feel
that they ought to comply with their promises.
7
8 WHO Framework Convention on Tobacco Control
15. Why should the FCTC be
developed and negotiated under
the auspices of the World Health
Organization, rather than, for
example, under the umbrella of
the United Nations ?
The World Health Organization is the only
international multilateral organization that
brings together the technical and public health
expertise necessary to serve as a platform for
the negotiation and effective implementation of
the Framework Convention on Tobacco
Control. Although the United Nations also has
the legal authority to sponsor the creation of
international instruments on tobacco control,
the UN has neither the specialized technical
expertise nor, perhaps, the time to engage in
negotiating complex standards on tobacco
control, particularly if extensive negotiation of
the Convention is required.
Complex technical standards on tobacco
control should be established and monitored
by WHO, the primary specialized agency in
public health. In WHA 49.17 Member States
recognized the unique capacity of WHO to
serve as a platform for the adoption ofthe
FCTC by calling upon the Organization to
initiate the development ofthe Convention.
However, in so far as the ultimate goal of
global tobacco control may require the
regulation of areas falling within the mandate of
other United Nations’ Bodies establish-ment of
a joint negotiating mechanism, especially with
regard to possible specialized protocols, could
be considered as an option.
16. What linkages will the work
on the FCTC have with other
regional /international agreements,
which could have added value
for the FCTC ?
Under the WHO/UNICEF project, “Building
alliances and taking action to create a
generation of tobacco-free children and
youth, supported by the United Nations
Foundation, a review ofthe Convention on the
Rights of the Child with respect to tobacco
control, is currently being conducted. Also,
with respect to TFFs work on strengthening the
role of women in global tobacco control,
possible links between the FCTC and the
United Nation’s Convention on the Elimination
of all Forms ofDiscrimination Against Women
(CEDAW), will be considered. Links between
the FCTC and other international treaties
addressing issues such as smuggling will also be
examined. Furthermore, all efforts will be made
to build on proposed and existing regional
tobacco control agreements.
The Tobacco Free Initiative is a new WHO cabinet
project created with the express aim offocusing
international attention and resources on the global
tobacco epidemic - the cause of a vast and entirely
avoidable burden of disease.
I
RESOLUTION
OF THE
WORLD HEALTH ASSEMBLY
FIFTY-SECOND WORLD HEALTH ASSEMBLY
Agenda item 13
WHA52.18
24 May 1999
Towards a WHO framework convention
on tobacco control
<
The Fifty-second World Health Assembly,
Being deeply concerned by the escalation of smoking and other forms of tobacco use worldwide,
which resulted in the loss of at least 3.5 million human lives in 1998 and is expected to cause at least
10 million deaths a year by 2030 if the pandemic is not controlled, with 70% of these deaths occurring in
developing countries;
Having considered the report of the Director-General to the Health Assembly on the Tobacco Free
Initiative, and the outline of expected activities (annexed);
Recognizing the leadership of the Director-General and WHO in the field of tobacco control;
Recalling and reaffirming resolution WHA49.17 requesting the Director-General to initiate
development of a WHO framework convention on tobacco control in accordance with Article 19 of the
WHO Constitution;
Recognizing the need for multisectoral strategies, including the involvement of other multilateral
organizations and nongovernmental organizations, to foster international consensus and action on
development of the WHO framework convention on tobacco control and possible related protocols;
Being mindful of the many constraints, including resource constraints, faced by a number of
countries in the development and implementation of the WHO framework convention on tobacco control
and possible related protocols;
Being also mindful of the fact that tobacco production is a significant source of earnings in many
developing countries;
Being aware of the urgent need to speed up work on the proposed WHO framework convention on
tobacco control and possible related protocols so that they may serve as a basis for multilateral cooperation
and collective action on tobacco control;
Desiring to complete preparation of the draft text of the framework convention for consideration by
the Fifty-sixth World Health Assembly,
WHA52.18
1.
DECIDES:
(1) in accordance with Rule 42 of its Rules of Procedure, to establish an intergovernmental
negotiating body open to all Member States to draft and negotiate the proposed WHO framework
convention on tobacco control and possible related protocols;
(2) to establish a working group on the WHO framework convention on tobacco control open to
all Member States in order to prepare the work of the body referred to above. This group will
prepare proposed draft elements of the WHO framework convention on tobacco control. The
working group will report on progress to the Executive Board at its 105th session. It will complete
its work and submit a report to the Fifty-third World Health Assembly;
(3) that regional economic integration organizations constituted by sovereign States, Members
of the World Health Organization, to which their Member States have transferred competence over
matters governed by this resolution, including the competence to enter into treaties in respect to these
matters, may actively participate, in accordance with Rule 55 of the Rules of Procedure of the Health
Assembly, in the drafting and negotiations of the intergovernmental negotiating body referred to
under paragraph (1) and in the preparatory work of the working group referred to under
paragraph (2);
2.
URGES Member States:
(1) to give high priority to accelerating work on development of the WHO framework convention
on tobacco control and possible related protocols;
(2)
to provide resources and cooperation necessary to accelerate the work;
(3) to promote intergovernmental consultations to address specific issues, for example, public
health matters and other technical matters relating to negotiation of the proposed WHO framework
convention on tobacco control and possible related protocols;
(4) to establish, where appropriate, relevant structures, such as national commissions, for the
WHO framework convention on tobacco control and mechanisms to examine the implications of a
framework convention on tobacco control within the context of health and economic issues,
especially its effects on the economy of agriculturally dependent States;
(5) to facilitate and support the participation of nongovernmental organizations, recognizing the
need for multisectoral representation;
(6) to consider further development and strengthening of national and regional tobacco policies,
including the appropriate application of regulatory programmes to reduce tobacco use, as
contributions to development of the framework convention and possible related protocols;
3.
REQUESTS the Director-General:
(1) to promote support for development of the WHO framework convention on tobacco control
and possible related protocols among Member States, organizations of the United Nations system,
other intergovernmental, nongovernmental and voluntary organizations, and the media;
2
WHA52.18
(2) to complete the technical work required to facilitate negotiations on the WHO framework
convention on tobacco control and possible related protocols;
(3) to convene the working group on the WHO framework convention on tobacco control, and
the first meeting of the intergovernmental negotiating body on the basis of progress achieved by the
working group;
(4) to provide the working group on the WHO framework convention on tobacco control and the
intergovernmental negotiating body with the necessary services and facilities for the performance
of their work;
(5) to facilitate the participation of the least developed countries in the work of the working group
on the WHO framework convention on tobacco control, in intergovernmental technical
consultations, and in the intergovernmental negotiating body;
(6) to invite, as observers at the sessions of the working group on the WHO framework
convention on tobacco control and the intergovernmental negotiating body, representatives of non
Member States, of liberation movements referred to in resolution WHA27.37, of organizations of
the United Nations system, of intergovernmental organizations with which WHO has established
effective relations, and of nongovernmental organizations in official relations with WHO, who will
attend the sessions of those bodies in accordance with the relevant Rules of Procedure and
resolutions of the Health Assembly.
3
WHA52.18
Annex
OUTLINE OF EXPECTED ACTIVITIES
January 1999 to May 2000 (completion of pre-negotiation phase), and targets for negotiation and
adoption of the WHO framework convention on tobacco control and possible related protocols
(May 2000 to May 2003)
Governing and
subsidiary bodies
Executive Board
Decision and actions by
governing and subsidiary bodies
• Recommend for adoption by the
Fifty-second World Health
Assembly the resolution
“Towards a WHO framework
convention on tobacco control”
May 1999
Fifty-second
World Health
Assembly
• Consider the draft resolution
“Towards a WHO framework
convention on tobacco control”
• Establish the intergovernmental
negotiating body and the
working group on the framework
convention on tobacco control
May 1999 to
January 2000
Working group on
the framework
convention
• Initiate preparation of proposed
draft elements of the WHO
framework convention on
tobacco control
January 2000
Working group on
the framework
convention
• Submit progress report of the
working group on the framework
convention to the Executive
Board at its 105th session
• Consider the progress of the
working group
• Continue work based on
direction from the Executive
Board
• Submit report of the working
group on the framework
convention to the Fifty-third
World Health Assembly
• Hold the first organizational
session
Milestones
January 1999
Executive Board
January 2000
to May 2000
May 2000
May 2000
(target date)
Working group on
the framework
convention
Fifty-third World
Health Assembly
I ntergovemmental
negotiating body
Action by the Secretariat
After the 103rd session of the
Executive Board
• Disseminate information on the
process for developing the
framework convention
• For the Fifty-second World
Health Assembly, prepare
briefing document(s) on the
process
• Hold consultations with
Member States
• Hold briefing sessions on the
framework convention during
the Fifty-second World Health
Assembly
After the Fifty-second World
Health Assembly
• Support intergovernmental
technical consultations on the
framework convention
• Facilitate participation of least
developed countries in the
process for developing the
framework convention
• Provide technical support
• Convene the working group on
the WHO framework
convention on tobacco control
• Provide technical support
• Provide technical support
• Provide technical support
• Hold technical briefing during
the Health Assembly on
alternative negotiation
processes
• Convene the first meeting of
the intergovernmental
negotiating body based on
progress achieved by the
working group
• Provide technical support
I ntergovemmental • Negotiate the draft framework
May 2000 to
May 2003
convention and possible related
negotiating body
(Target date
protocols
for adoption)______________________________
Note: Process and content will be driven primarily by Member States, but will also include input from bodies of
the United Nations system, other international, regional, or intergovernmental organizations, and
nongovernmental organizations.
Ninth plenary meeting, 24 May 1999
A52/VR/9
4
RESOLUTION
OF THE
EXECUTIVE BOARD OF THE WHO
103rd Session
EB103.R11
Agenda item 3
29 January 1999
Towards a WHO framework convention on
tobacco control
The Executive Board,
Recognizing the leadership of WHO in the field of tobacco control, and having considered the report
of the Director-General on the Tobacco Free Initiative1 and the outline of expected activities,2
RECOMMENDS to the Fifty-second World Health Assembly, the adoption of the following
resolution:
The Fifty-second World Health Assembly,
Being deeply concerned by the escalation of smoking and other forms of tobacco use
worldwide, which resulted in the loss of at least 3.5 million human lives in 1998 and is expected to
cause at least 10 million deaths a year by 2030, with 70% of these deaths occurring in developing
countries if the pandemic is not controlled;
Having considered the report of the Director-General on the Tobacco Free Initiative and the
outline of expected activities (annexed);2
Recognizing the leadership of the Director-General and WHO in the field of tobacco control;
Recalling and reaffirming resolution WHA49.17 requesting the Director-General to initiate
development of a WHO framework convention on tobacco control in accordance with Article 19 of
the WHO Constitution;
Recognizing the need for multisectoral strategies, including the involvement of other
multilateral organizations and nongovernmental organizations, to foster international consensus and
action on development of the WHO framework convention on tobacco control and possible related
protocols;
Being mindful of the many constraints, including resource constraints, faced by a number of
countries in the development and implementation of the WHO framework convention on tobacco
control and possible related protocols;
1 Document FBI03/5.
2 Annex.
EB103.R11
Being mindful of the fact that tobacco production is a significant source of earnings in many
developing countries;
Being aware of the urgent need to speed up work on the proposed WHO framework
convention on tobacco control and possible related protocols so that they may serve as a basis for
multilateral cooperation and collective action on tobacco control;
Desiring to complete preparation of the draft text of the framework convention for
consideration by the Fifty-sixth World Health Assembly;
1.
DECIDES:
(1)
in accordance with Rule 42 of its Rules of Procedure, to establish an intergovernmental
negotiating body open to all Member States to draft and negotiate the proposed WHO
framework convention on tobacco control and possible related protocols;
(2) to establish a working group on the WHO framework convention on tobacco control
open to all Member States in order to prepare the work of the body referred to above. This
group will prepare proposed draft elements of the WHO framework convention on tobacco
control. The working group will report on progress to the Executive Board at its 105th
session. It will complete its work and submit a report to the Fifty-third World Health
Assembly.
2.
URGES Member States:
(1) to give high priority to accelerating work on development of the WHO framework
convention on tobacco control and possible related protocols;
G)
to provide resources and cooperation necessary to accelerate the work;
(3) to promote intergovernmental consultations to address specific issues, for example,
public health matters and other technical matters relating to negotiation of the proposed WHO
framework convention on tobacco control and possible related protocols;
(4) to establish national commissions for the WHO framework convention on tobacco
control where appropriate;
(5) to facilitate and support the participation of nongovernmental organizations,
recognizing the need for multisectoral representation;
(6) to consider further development and strengthening of national and regional tobacco
policies, including the appropriate use of regulatory programmes to reduce tobacco use, as
contributions to development of the framework convention and possible related protocols;
3.
REQUESTS the Director-General:
(1) to promote support for development of the WHO framework convention on tobacco
control and possible related protocols among Member States, organizations of the United
Nations system, other intergovernmental, nongovernmental and voluntary organizations, and
the media;
2
EB103.R11
(2) to complete the Organization’s technical work required to facilitate negotiations on the
WHO framework convention on tobacco control and possible related protocols;
(3) to convene the working group on the WHO framework convention on tobacco control
and the first meeting of the intergovernmental negotiating body based on progress achieved
by the working group;
(4) to provide the working group on the WHO framework convention on tobacco control
and the intergovernmental negotiating body with the necessary services and facilities for the
performance of their work;
(5) to facilitate the participation of the least developed countries in the work of the working
group on the WHO framework convention on tobacco control, in intergovernmental technical
consultations and in the intergovernmental negotiating body;
(6) to invite, as observers to the sessions of the working group on the WHO framework
convention on tobacco control and the intergovernmental negotiating body, representatives
of non-Member States, of liberation movements referred to in resolution WHA27.37, of
organizations of the United Nations system, of intergovernmental organizations with which
WHO has established effective relations, and of nongovernmental organizations in official
relations with WHO, who will attend the sessions of those bodies in accordance with the
relevant Rules of Procedure and resolutions of the Health Assembly.
Tenth meeting, 29 January 1999
EB103/SR/10
3
EB103.RI1
ANNEX
OUTLINE OF EXPECTED ACTIVITIES
January 1999 to May 2000 (completion of prenegotiation phase), and targets for negotiation and
adoption of the WHO framework convention on tobacco control and possible related protocols
(May 2000 to May 2003)
Milestones
Governing and
subsidiary bodies
Decision and actions by
governing and subsidiary bodies
January 1999
Executive Board
• Recommend for adoption by the
Fifty-second World Health
Assembly the resolution
Towards a WHO framework
convention on tobacco control
After the 103rd session of the
Executive Board
• Disseminate information on the
process for developing the
framework convention
• For the Fifty-second World
Health Assembly, prepare
briefing document(s) on the
process
• Hold consultations with
Member States
May 1999
Fifty-second
World Health
Assembly
• Consider the draft resolution
Towards a WHO framework
convention on tobacco control
• Establish the intergovernmental
negotiating body and the
working group on the framework
convention on tobacco control
• Hold briefing sessions on the
framework convention during
the Fifty-second World Health
Assembly
After the Fifty-second World
Health Assembly
• Support intergovernmental
technical consultations on the
framework convention
• Facilitate participation of least
developed countries in the
process for developing the
framework convention
• Provide technical support
May 1999 to
January 2000
Working group on
the framework
convention
• Initiate preparation of proposed
draft elements of the WHO
framework convention on
tobacco control
• Convene the working group on
the WHO framework
convention on tobacco control
• Provide technical support
January 2000
Working group on
the framework
convention
• Submit progress report of the
working group on the framework
convention to the Executive
Board at its 105th session
• Consider the progress of the
working group
• Provide technical support
Executive Board
Actions by the Secretariat
January 2000
to May 2000
Working group on
the framework
convention
• Continue work based on
direction from the Executive
Board
• Provide technical support
May 2000
Fifty-third World
Health Assembly
• Submit report of the working
group on the framework
convention to the Fifty-third
World Health Assembly
• Hold technical briefing during
the Health Assembly on
alternative negotiation
processes
May 2000
(target date)
Intergovernmental
negotiating body
• Hold the first organizational
session
• Convene the first meeting of
the intergovernmental
negotiating body based on
progress achieved by the
working group
• Provide technical support
May 2000 to
Intergovernmental • Negotiate the draft framework
May 2003
convention and possible related
negotiating body
(Target date
protocols
for adoption)__________________________________________
Note: Process and content will be driven primarily by Member States, but will also include input from bodies of
the United Nations system, other international, regional, or intergovernmental organizations, and
nongovernmental organizations.
4
Ku
TOBACCO rRet INITIATIVE
The Tobacco Free Initiative is a new cabinet
project for the WHO created with the
express aim of focusing international
attention and resources on the global
tobacco epidemic which is an entirely
avoidable burden of disease.
Ii
Dr Derek Yach
Project Manager
Tobacco Free Initiative
World Health Organization
1211 Geneva 27
Switzerland
Tel:+41 22 791 2736
Fax:+41 22 791 4769
E-mail: yachd@who.ch
Photography, concept and design
Ashvin Gatha & Tushita Bosonet
Living Color, CH-1807 Blonay
..r.7
Vforld No-Tobacco Day
31 May 1999
The threat
A cigarette is the only consumer product which
lar the pharmaceutical industry, international fun
when consumed as indicated, kills.The tobacco
ding institutions, NGO's and civil society institu
industry goes to great lengths to keep that "infor
tions. This is only the beginning.
The threat from tobacco and tobacco
smoke concerns us all
mation" away from a public whose freedom it
Tobacco is about statistics and it is about people. It
is about people who smoke and those who don't
claims to espouse. A secret tobacco industry docu
ment says "Countermeasures designed to contain/
neutralise/re-orient the WHO:
Tobacco control cannot succeed solely through
the efforts of individual governments, NGO's,
industry and media advocates. The WHO's res
because when you smoke, everyone near you
• direct and indirect initiatives towards the organi
ponse to this global scourge is the Framework
smokes. Every nine seconds, another person dies
sation itself, its management, its resource alloca
Convention on Tobacco Control, the world's first
because of a tobacco-related illness. Tobacco kills
tion, its priorities;
public health treaty expected to be adopted by
3.5 million people annually, a figure slated to triple
in the first quarter of the next century. It doesn’t
• specific strategies and plans to blunt their pro
gramme initiatives."
member-countries by 2003. The FCTC is the glo
bal framework. Solutions will be local.
have to be that way.
Tobacco is about profits and losses calculated with
human beings at the centre of the equation. It is
about loss to national treasuries due to enhanced
health costs, lost productivity and wasted foreign
exchange. Tobacco inflicts substantial economic
The opportunity
You can do it!
The defining moment for global
tobacco control has come
The World No Tobacco Day (31 May, 1999) this
costs on governments, businesses and industry.
The World Health Organisation's Tobacco Free
There are no economic or public health arguments
Initiative (TFI) is spearheading a global effort to
in favour of tobacco.
educate the public and policy makers worldwide
about the effects of smoke and smoking on public
Tobacco is about clear threats to free choice.
Nicotine is addictive. Over 80 percent of today's
smokers started before they were 18. The decision
to smoke is enhanced by advertising. The addicti
■V
veness of tobacco and its sales and promotion
health. The World Bank has joined this effort by
declaring that tobacco control is a top priority health
problem. UNICEF has come in with a clear message
to protect children and youth from tobacco. The
alliance grows by the day.
informed decisions. By the time they find out, it is
lt can be done. Smoking trends can be bucked, if
often too late.
not reversed. Cost-effective interventions and the
right mix of policy - taxation, bans on advertising
loped countries, smoking rates are increasing,
aimed at smoking cessation and encourages cur
rent smokers to take the critical first step towards
reducing risks to their health. Tobacco has been
shown to cause twenty five life-threatening
diseases many of which can be prevented,
delayed or mitigated by smoking cessation.
Quitting smoking is not easy because nicotine is
very addictive. But it can be done with the help
of lasting and cost-effective treatments. If you are
a smoker looking to quit, just tell yourself that
you can do it too - this could be the year when
pitch severely handicaps people's freedom to make
The global tobacco epidemic rages. In many deve
year salutes all those individual and group efforts
and promotion, effective cessation - has led to
reduced smoking prevalence in many countries.
especially among women and youth. As the epide
mic spreads to the South, many developing coun
Tobacco control is about the globalisation of res
tries are unprepared foTit. We all deserve the same
ponsibilities. Partnerships are already emerging,
levels of information and protection.
between the WHO-TFI and the industry in particu
you leave the pack behind.
Vol. 2 June 1999
A Quarterly from the WHO South-East Asia Region on Tobacco & Alcohol issues
MAPPING AN AGENDA FOR TOBACCO AND ALCOHOL
CONTROL IN THE SOUTH-EAST ASIA REGION :
STEPS ON THE PATH TO PROGRESS
(When spider webs unite,
they can tie up a lion ’
- Ethiopian proverb
The development of a policy framework
marks a historic milestone in our collective
march towards a tobacco-free Region. A
Region where excessive alcohol use is no more
the norm. A Region whose peoples are
supported to adopt healthier life-styles and
thus improve their quality of life.
Dr Uton Muchtar Rafei, Regional Director, WHO SouthEast Asia Region.
"V IT "THO’S intensified leadership role in controlling
/ the use of tobacco and alcohol comes at a time
▼ V when the Region is going through an
epidemiological transition. A time when non-communicable
diseases are gradually emerging as major killers in some
countries in the Region, with tobacco and alcohol use being
identified as significant contributors to the rising incidence.
It is necessary to protect the health gains made during the
past decade in the Region and to provide direction for the
control of these two substances. This means highlighting
the dangers that increased tobacco and alcohol use pose to
the socio-economic development of the Region, the need
for intensified political commitment at all levels, and
protecting the most vulnerable sections of society - children,
youth, women and the poor.
The Regional Director’s address at the Regional
Consultation on “A Policy Framework for Tobacco and
Alcohol Control” held in Bangkok set the stage for a Regional
Policy Framework and Plan of Action 2000-2004, that
proposes to effectively tackle these problems as we enter
the 21st century. The previous Regional Consultation, held
at Colombo in November 1997, had reviewed
the situation as regards tobacco and alcohol
use and the associated preventive
programmes. It also made recommendations
towards strengthening control strategies.
The Bangkok consultation, held from 12-16
October 1998, was a follow-up to the
Colombo meeting. It saw a gathering of
experts in the field of tobacco and alcohol
control from nine of the ten Member countries
of the Region. Pointing out that the problems
caused by the indiscriminate use of tobacco
and alcohol had reached alarming proportions,
setting in motion the vicious cycle of poverty, malnutrition
and disease, Dr Rafei set out the objectives of the
Consultation by emphasising that ‘we in this Region need
not. and cannot, remain inactive. We need to protect the
lives of millions of children who are potential tobacco and
alcohol users, from adopting these habits. Importantly, there
is need to protect the health gains made by the Region during
the last decade.'
The policy framework outlines the priority actions to be
undertaken and the strategies which should be adopted by
Member countries. It aims to be responsive to the regional
tobacco and alcohol situation in the context of the specific
resources and special needs of the Member countries. It
includes a five-year plan (2000-2004) for tobacco and alcohol
control in the Region. To facilitate the implementation of the
Action Plan, it was recommended that all countries of the
Region should give priority to implementing national pro
grammes on a sustained basis. It was also suggested that
each country should designate an authority with an adequate
budget to handle tobacco and alcohol control issues. The
meeting urged the WHO Regional Office to facilitate the
adoption of the five-year action plan by all Member countries,
ensure their implementation and evaluation, and also provide
financial and technical assistance.
HIGHLIGHTS INSIDE
2
3-6
6-7
8-10
11
12
13-15
16
A Commentary
from the
South-East
Asia Region
Living Under the
Looming Clouds of a
Tobacco Epidemic
Young Voices
Protest
Tobacco Source
Smoking and
Lung Cancer:
Statistics
and Strategies
from Thailand
Partnerships for
Tobacco Control
The Case Against
Gutka in India
Interview
The Tobacco
Free Initiative Dr. Hem Raj Pal
World
No-Tobacco Day
1999
Cessation
PROFILE
A COMMENTARY FROM
THE SOUTH-EAST ASIA REGION
THEN Koop, Kessler and
Lundberg wrote their
▼ ▼ editorial ‘Reinventing American
Tobacco Policy’ in the Journal of the
American Medical Association in February
1998, they were hopeful that the American
public health sector, legislators and the
community at large would finally grasp the
political nettle of tobacco control and rein in
the tobacco industry. Their hopes were dashed Judith Mackay, frcp,
Director, Asian
when the talks collapsed and the Tobacco Consultancy on Tobacco
Control Bill was defeated on Capitol Hill. Control, Hong Kong
The scuttling of the McCain Bill with its
strong international provisions was also a
major set back. But fortunately, a cable from
the State Department to US embassies
around the world put a spanner into the
works of the pro-tobacco lobby, with
strictures that would prove difficult to
disobey. This news was especially
welcomed in Asia. Many previously hidden
tobacco industry documents with a wealth
of ‘inside’ information have been made
public and even placed on the Internet.
Since the demise of the settlement talks and the McCain
Bill, the overall legislative situation within the US has
become ‘a peculiarly dispersed affair.’ The fact is that
any American law or settlement
that excludes the rest of the world
or attempts to give the tobacco
companies global immunity is
unethical and will be ineffective
from a public health perspective.
As with malaria, the tobacco
epidemic is a cross-border issue; the tobacco industry,
like the mosquito, operates across borders. In order to
safeguard developing countries, an international code
of conduct should be agreed upon and the US tobacco
companies be asked to stick to this. Some countries
like Guatemala and Israel are following the US example
in claiming tobacco-attributable health care costs on
the ‘polluter pays’ principle - an industry should pay
for the damage it causes. This is an avenue for all
countries to pursue, especially those with limited
budgets for health and socio-economic development.
The article clearly spelt out the amoral conduct of the
tobacco industry, its aggressive marketing strategies
and obstruction of government action. Every corner of
the globe has been exposed to sophisticated and
seductive tobacco promotion, especially since the
introduction of satellite, cable and Internet advertising.
As cigarette markets shrink in the West, inroads are
being made into the developing world. In the US,
tobacco companies have increased their exports by
260%. All evidence shows that developing countries
will bear the brunt of the tobacco epidemic in the next
century. WHO predicts that 10 million people will die
annually from tobacco related diseases by 2030, and
of these, 70% will belong to the developing world.
The 1997 settlement talks would have settled lawsuits,
restricted advertising, regularised standards for overseas
marketing and provided funding for international tobacco
control. However, in June 1997, tobacco control
advocates from 19 countries
including Hong Kong, Japan,
Malaysia, Thailand, Philippines,
India and others asked that
measures be included to control
the use of US tobacco products
outside of the United States.
Editor’s note: Anti-tobacco advocates in the Region
could learn from the experiences ofother countries.
Legal resources should be mobilised to bring
pressure to hear on the tobacco industry to pay for
the harm knowingly caused by them.
2
REPORT
LIVING UNDER THE LOOMING CLOUDS OF A
TOBACCO EPIDEMIC :
IN THEIR OWN WORDS - TOBACCO INDUSTRY DOCUMENTS
IGARETTE consump
tion has
gradually
decreased in developed
countries since 1980-82. However,
this decrease has been counter
balanced by a comparable
increase in consumption (1.4%
per year) in developing countries.
In the early 1970s average
cigarette consumption per adult
was 3.3 times higher in
developed countries than that in
the developing ones. By the early
1990s, this ratio decreased to 1.8.
among women (15+ years)
ranges between a low of 3% to a
high of 71.7% and between 55%
to 80% among adult men.
In the South-East Asia Region,
these percentages translate into
millions of cigarette users
considering the huge population
of the Region. But that is not the
end of the story. The use of
cottage and home produced, oral
tobacco products is steadily
getting entrenched in many
countries of the Region.
WHO estimates that if the
current trend continues, per adult
consumption in developing
countries will outstrip that of
developed countries shortly.
Already, 800 million of the
world’s estimated 1.2 billion
smokers live in developing
countries. It is estimated that by
2020, the transfer of the tobacco
epidemic from rich to poor
countries will be well advanced
with only about 15% of the world’s
smokers living in rich countries.
The Region has the unenviable
distinction of having the greatest
variety of tobacco products used
in intricate modes. The bidis,
chuttas, keeyos, mawa, water
pipe, cheroots, keteks, cigars,
dhumti, hookli, chilum, hookah
are but a few of the smoking
types of tobacco products
readily available in the market and
accessible to whoever may buy.
And so are the smokeless
tobacco products. Pan and pan
masala products, usually found
to be a concoction of low quality
tobacco and dangerous
ingredients, such as slaked lime
(CaO) areca nuts etc., has grown
into a million dollar industry in
some countries in the Region.
Other oral preparations such as
gundi, zarda, kiwams, pattiwala
are also used particularly in rural
areas of some countries.
For the countries of the SouthEast Asia Region these are
alarming facts. Prevalence of
cigarette smoking is increasing
across sections of the population,
with the most vulnerable children, the young, women and
the poor — being most affected.
The prevalence of smoking
3
—
The frightening spate in the
consumption of the varied
tobacco products in the Region
has set some scientists and
government officials urging for
stronger control measures. While
this is a positive sign, it is
imperative to examine the total
socio-economic context within
which the tobacco industry
thrives. Important to this analysis
is the streaming influx of
multinational tobacco companies
into the Region and their crude
tactics of wooing children to their
death as they keep smokers
smoking.
As far back as the 1960s, the
tobacco industry had strategised
its marketing network to capture
the market made up of children
and the young in developing
countries including those of the
South-East Asia Region.
Even though the industry
strongly denies marketing to
children their own documents say
otherwise.
In the course of the law suits in
Minnesota USA, it is clear that
marketing to children is a
worldwide phenomenon. The
industry says they market only
for young “starters” but 80-90%
of adults who smoke ‘started’
in their adolescence. From a
secret document discovered in
British American tobacco files an
undated, unsigned and hand
written document on India
describes Project Kestrel, “a
plan to develop a brand which
breaks the rules, to appeal to a
new generation and shock their
parents” a brand which would
be completely unconventional,
encouraging their rebellion not
necessarily just against parents
but also an alternative drug.
It continues.
“The packet would reflect the
durable youth values of
rebellion, glamour & danger,
-etc., by being distinctively
black.” On 14 August 1997 an
embarrassed BAT attorney
claimed that “Project Kestrel”
was just some marketing idea
that was not “even close to
being commercialized.”-Yet an
advertisement in the Navahind
Times (Goa, India) only the
week before the launch of
BAT’s new product. “Just
Black” (10 to a pack,
affordable for youngsters)
shows a rebellious adolescent
school girl extolling the
dangerous virtues of her
motorbiking boyfriend and Just
Black cigarettes. In the tiniest
print possible and almost falling
off the page (lower left) is the
“Statutory Warning: Cigarette
Smoking Is Injurious To
Health.” Details and photos
may be found at <wwe.gate.net/
-jeannon/tobacco.html>.
Again from its tobacco industry
trade journal it says :
“With economic reforms taking
place and foreign influence
becoming more and more
important, Indian cigarette
manufacturers are optimistic
that their sales will grow
licensing arrangements as they
boasted, “last year we recorded
double-digit volume growth.”
(PM 2044747411,24 February
1995.)
strongly in the near future... With
a population of900 million, India
is a country of big numbers and
big opportunities. While the
Indians turn their attention to
western trends, which become
more and more important in the
country, the industry hopes that
the global trend towards cigarette
smoking will establish itself
within Indian society...
From a Philip Morris marketing
briefing book: the industry
indicates that Indonesia is the
fastest growing market in the
world and already the fifth
largest, and Marlboro is growing
well off a small base. (PM
2048306518,1 January 1994.)
As a matter of fact and apart
from governmental pressure, the
world-wide anti-smoking
campaigns have not arrived in
India yet. Indians can still smoke
almost everywhere, and cigarette
advertising often links the act of
smoking to success in life or
portrays young people, something
forbidden in several countries
around the globe.” (Tobacco
Journal International, September/
October 1995. Pp. 16-25.)
It continues, “The key to our
success in Indonesia will be
effective government relations.
Will Rajawali group be able to
provide this?” (CD52048300197,
19 January 1993).
From dissident, minority Philip
Morris stockholder’s resolution,
“Domestic and Foreign
Lobbying, the company states:
On Bangladesh, the tobacco
industry’s trade journal: “Up and
Coming” states, “the future
looks bright for the Bangladesh
tobacco industry. Good value is
important in Bangladesh, where
the per capita income is a mere
USD 220.- Most of the
population live day-to-day. Only
about 20% of the 123 m
Bangladeshis smoke tobacco..
The cigarette market is growing
at 6.4 percent annually. With new
joint ventures on the way, the
introduction of new brands is
bound to follow.” (Tobacco
Reporter, October 1998. Pp.
148-149.)
“The US tobacco industry,
including our company, has
lobbied to open markets in
foreign countries, especially in
Asia, to U.S. brands (under
Section 301 of the 1974 Trade
Act.) Part of the resulting trade
agreement allows our company
broad advertising rights with
little or no warnings, with much
of this advertising impacting
women and children. Since the
opening of these markets,
smoking of our company’s
products has increased
dramatically. From 1985-87, the
percentage of teenagers
smoking in Taiwan (province of
China) increased from 26% to
53% for males and less than 1 %
In Indonesia, the industry was
determined to continue with the
5
a Aa
VOICES
YOUNG VOICES PROTEST
TOBACCO SCOURGE
to 13% for females, with the
brand of choice being
Marlboro. (CD5 250021899.
About 1989.)
■^pvOLICIES that do not effectively address vital
l-^issues that affect the lives of young people, such
as tobacco consumption, will take its toll of the
generation which is presently at school. In raising their
voices against practices that undermine their health,
young people learn to be committed to individual and
societal health promotion as they grow to become
decision makers at various levels. Dr. K. Srinath
Reddy, Professor of Cardiology, All India Institute of
Medical Sciences, Co-ordinator of HRIDAY (Health
Related Information Dissemination Amongst Youth)
and SHAN (Student Health Action Network), two
organisations that seek to empower youth with these
qualities, shares some experiences.
Unfortunately, a similar trend is
evolving in the countries of the
South-East Asia Region. Do we
need to look for further examples?
In every country tobacco
companies claim to be “good
corporate citizens”, buying
goodwill by donations to the
Government, communities,
groups and farmers. But their
real motive can hardly be
hidden.
The formal launch of SHAN, whose motto is:
‘Debate the present to define the future,’ took
In Sri Lanka, BAT sponsors
lavish discos at which nubile
“golden girls” hand out free
cigarettes; BAT circumvents the
ban on radio advertising by
underwriting contests aimed at
teens. (Addicted to Profit: Big
Tobacco’s Expanding Global
Reach by Ross Hammond,
published by Essential Action,
P.O. Box 19405, Washington DC
20036, The document is on the
web at www.essential.org/
action/addicted.)
Can any government close its
eyes to such blatant anti-health
activities on the part of the
tobacco industry? Any effective
tobacco control measures
would necessarily need to curb
the excesses of the tobacco
industry. It is time to act and act
decisively to protect the
vulnerable groups in our
countries.
place on the 12th of September 1998. SHAN has
been instrumental in organising a student charter on
sustainable health, through a project that evolves
consensus among school students on the broad
determinants and specific needs of sustainable health
over a lifespan. It has also organised inter-school
debates on governmental action to ban tobacco
advertising, culminating in a memorandum to the Prime
Minister of India, signed by 25,000 school students
of Delhi.
6
The appeal reads:
Respected Prime Minister,
We write this to convey the concerns of all young
people in this country about the threat that tobacco
poses for our future. While we look forward to
building an India of our dreams, we are also
conscious that tobacco is one of the major
problems we need to overcome on that path . Here
are the reasons for our concern:
9 Tobacco now claims over 3.5 million lives per
year. The annual toll will be 10 million by 2020.
tin India, deaths attributable to tobacco are
expected to rise from 1.4% in 1990 to 13.3% in
2020.
O Of every 1000 teenagers who smoke, 500 will
die of tobacco-related diseases. One half of
these will die in middle age, with an average
loss of 22 years of life expectancy, compared
to non-smokers. The other half will die from
tobacco's effects in their old age but will suffer
ill health from middle age.
These grim projections are from the WHO's First
Global Status Report on Tobacco or Health (1996).
We do not wish to become part of these statistics
nor do we wish other young people to become
victims of an addiction that leads to early death
or prolonged disabilityfrom heart attacks, cancers
and other diseases. All of us are vulnerable to the
dangers of passive smoking. Tobacco also
threatens our environment in many ways, including
deforestation - for every 300 cigarettes smoked,
someone somewhere has killed a tree.
We appeal to you to initiate measures to usher in
a tobacco-free society. World leaders who have
signed global conventions to ban chemical
and biological weapons must also launch a
global effort to eliminate the modern world's
biggest killer.
We recognize that tobacco provides ready
revenue. But we plead that our tomorrows should
not be bartered away for today's taxes. For
sustainable health and environment we need early
and effective tobacco control measures. There is
urgent need to educate people about the dangers
of tobacco and for strong governmental action.
We appeal to you to start this process by imposing
a comprehensive ban on all forms of tobacco
advertising. Surrogate advertising through
sponsorship of sports even ts has become rampan t
in recent years. The ban on tobacco advertising
on television and radio has been cleverly
subverted by promoting sports contests and
linking them to tobacco brands through other
products bearing their names. The wide reach of
television and the popular appeal of sports are
being exploited to target young persons. The
Government must intervene to stop such unethical
advertising which puts the future of millions of
Indians in jeopardy. There are many other ways
in which sports can be supported.
In the 50th year of our freedom, we salute your
generation which made great sacrifices in order
to liberate our country. We hope you will also
ensure that our freedom to lead healthy lives in
the future is not threatened by the dark clouds of
tobacco smoke that are forming today. Our health
is in peril! We trust you to defend it with all your
might!
With the highest esteem,
Yours sincerely......
The impact of an appeal such as this is all the more significant when we consider that it is young people
themselves who are speaking out. Power to transform a society rests primarily in the hands of its youth. It is only
through the growth of organisations like HRIDAY and SHAN that public awareness on the ill-effects of tobacco
can increase. Any movement against tobacco needs a concerted and sustained effort on the part of the community.
Laws and regulations are inadequate unless backed by people’s power, based on the understanding of related
risks and the benefits of control.
INITIATIVES
SMOKING AND LUNG CANCER :
STATISTICS AND STRATEGIES FROM
THAILAND
The epidemic of lung cancer attributable to cigarette smoking began in
Western Europe and the USA over 70 years ago. It is now a malaise of
many dimensions that has grown to alarming proportions in developing
countries. Dr Thira Limsila, recipient of the WHO Tobacco or
Health Medal 1998, outlines the history of tobacco in
Thailand and suggests strategies to fight it.
F I 1OBACCO was introduced into Europe from
America in the 16th century, and before long,
A its harmful effects were understood by the
British. King James I (1603-1625) imposed taxes on
imported tobacco, and described smoking as ‘ a
custom loathsome to the eye, hateful to the nose,
harmful to the brain, dangerous to the lungs....’. In
1853 and 1854, the first tobacco factories were set
up in the USA and UK, and in 1900, the first cigarettes
yvere imported to Thailand. In the early 1900s many
cigarette factories mushroomed
in Thailand, but in 1939, all the
private factories were bought
by the Government and the Thai
Tobacco Monopoly (TTM)
was established.
professor visiting Thailand from the US in 1955 and
1963, drew public attention to the dangers of cigarette
smoking and lung cancer in this
country, over half a century after
the first cigarette was imported
into Thailand.
It was predicted that after
1993, over 10,000 new lung
cancer cases would be
diagnosed each year and that this number would
increase annually. Over 50% of these would die,
mostly within a year. Even with modern techniques
and advances in thoracic surgery and combined
adjuvant modalities, especially chemotherapy and/or
radiation, only 6% of patients will be cured or survive
beyond 5 years. From the economic point of view,
an even more depressing picture emerges.
As early as 1933, several
claims were made indicating that smokers seemed to
suffer more from lung cancer. In succeeding years, a
real increase in lung cancer deaths was noted and the
causal factors examined. In the 1950s, major
epidemiological studies in the US and UK proved the
causal relationship between prolonged cigarette
smoking and cancer of the lung.
All expenses taken together, from the cost of the
cigarettes to treatment, and adding inevitable indirect
costs, each patient and his family would suffer a loss
of more than 1.1 million baht (US$27,500).
On World No Tobacco Day
1998, the Director of the TTM
gave an interview to a
television programme on which
it was announced that the TTM
expected to make a profit for
the Government of around 30,000 million bahts (US$
750 million) that year. But what of the health care
The 1962 report by the Royal College of Physicians
in London and the 1964 warning by the Surgeon
General of the United States established beyond any
reasonable doubt the correlation between
cigarette smoking and lung cancer. Paul D. Rosahn, a
8
considerations and the millions of dollars that have to
be spent on curative measures? Data from the Ministry
of Public Health and the National Institute of Statistics
in 1996 indicated that there are 11.2 million smokers
in Thailand at present. For the
230,000 who quit smoking
every year, there are 750,000
new smokers, and of these
52,000 are under the age of
20. The number of Thais who
die each year from tobaccorelated illnesses is 42,000 and the annual death rate
is increasing. There seems to be no doubt that smoking
is the largest single preventable cause of ill health.
So what strategies can be adopted to fight this?
• Experience is an effective weapon. Not all the text
books and journals can replace the wisdom that
comes from actual collective experience. It is
therefore important to share
this knowledge and experience
and gain from interaction with
other professionals. A forum of
specialists could effectively
educate the larger community,
especially children, about the
dangers of smoking.
• Political support is vital if anti-smoking campaigns
are to be successful. Successive Governments must
be persuaded to bring in stricter laws and
restrictions. In 1992, a Bill was passed in Thailand
which prohibits, among other things, smoking in
designated public places, and all forms of cigarette
advertising and sales to people under 18. This has
yielded significant results. However, this needs to
be sustained and new laws enforced to reduce
further supply of and demand for tobacco
products.
• Funding from Government and national and
international agencies is essential for the success
of all these endeavours. When I started my work
30 years ago, we were not able to get adequate
funds. But over the years generous donations and
contributions from the government have helped
various aspects of our work, including clinical
research. Proper accumulation and dissemination
of information can go a long way in improving
methods of treatment. And this needs funds..
• Involvement of national and international
organizations and ministries other than health, in
taking action against smoking is vital. Ministries of
Public Health alone cannot stop
the use of tobacco in the
community. Other Ministries
and sectors dealing with
agriculture, employment,
industries , law and order, all
have a role to play.
• Professional associations can be instrumental in
policy formulation and surveillance for implementation.
The Asia Pacific Cancer Conference and the Asia Pacific
Conference on Tobacco or Health are two good
examples. Young medical students have to be guided and
motivated into working enthusiastically for such
causes. It is they who can influence their peers and
younger friends into working towards WHO's concept
of a society where tobacco use is no longer a social
norm.
• There is still a lot that needs to be done. The
community needs to be empowered with
information that enables them to say no to tobacco.
Those who smoke need to be supported to ‘leave
the pack behind’. These are
common, shared res
ponsibilities that we cannot
afford to ignore.
In the end, the real will to
live without tobacco and
strive for a world free of
it has to come from the individual himself No
law can enforce it in totality.
MULTI-PRONGED TOBACCO CONTROL
MEASURES IN THAILAND
The label and statement shall have the following
format:
In the early 1990s, Thailand launched a courageous
initiative to stop the entry of multinational tobacco
companies into the country. Although eventually the
country lost the battle, one of the concrete outcomes
was a strengthened national resolve to protect its
citizens from the hazards of tobacco.
1. The label and statement will cover an area,
including the frame, of not less than one-third
(33.3%) of the area on the front and the back
of the pack or carton containing the cigarette
packs as the case may be:
Thailand is today the only country in the WHO
South-East Asia Region which has a comprehensive
tobacco control policy backed by legislation. The
results have been encouraging, and the country has
not looked back since then. Action on Smoking
and Health Foundation (ASH), an NGO, has
commended the latest move of the Ministry of Public
Health to make its health warning requirements on
cigarette packets more effective. The new warning
announcements came into effect on 5 November
1998.
2. The frame shall be white and 2mm wide
3. The label’s background shall be black and
the statement white
4. The statement shall be in “sipraya” font. The
size of the print will differ in accordance with
the size of the carton or pack as follows:
The warning statements to be placed on cigarette
packs and cartons are listed below. All warnings
must be displayed at the ratio of one warning
statement per 5,000 packs and one warning per
500 cartons.
(a)
A pack having an area on the front or
the back of less than 37 square
centimeters shall use letters 20 points
in size.
(b)
A pack having an area on the front or
the back of more than 37 square
centimeters but less than 80 square
centimeters shall use letters 25 points
in size.
A pack having an area on the front or
the back of more than 80 square
centimeters shall use letters 38 points in
size.
(d) A carton containing cigarette packs shall
use letters of 75 points size.
(c)
1. Smoking causes lung cancer
2. Smoking causes heart failure
3. Smoking causes pulmonary emphysema
4. Smoking causes cerebrovascular diseases
5. Smoking leads to other narcotic addictions
6. Smoking reduces sexual ability
7. Smoking causes premature aging
8. Smoking kills
Editorial Note: Tobacco Control Advocates could
access further information on other Thai Legislation
from the Ash website ,<Ahttp://wwwMsh.or.th
Thai Situation section under legislation.
9. Smoking is harmful to your family and friends
10. Smoking is harmful to the foetus.
10
ACTION
PARTNERSHIPS FOR TOBACCO CONTROL :
LESSONS FROM INDONESIA
f ■ ^HE control of tobacco in the Region has received
increasing attention by non-governmental organizations. In an environment where government’s
express aim to control tobacco has been limited, the
role of NGOs has been critical. This has been the case
in Indonesia. Many public health societies and organi
zations have championed the cause of tobacco for the
past decade. One of these is the Indonesia Smoking
Control Society which was established in the early 90s.
During the past year activities of the Society have been
most encouraging. Dr Tjandra Y. Aditama shares some
of these activities:
earlier one started to smoke, the longer one will keep
smoking and the more difficult it is likely to quit. These
corelations were proven statistically significant. On average, the length of smoking was 8 years. However,
those who started earlier continued their smoking habit
for 23-27 years.
The results of the meta analysis research were pre
sented at a seminar on 27 May 1998 as part of World
No Tobacco Day Celebration.
The Society has also initiated a three-monthly bulletin
“Rokok & Masalahnya” (Smoking and its Problem) a
year ago, with the objective of educating the public on
tobacco hazards. Another monthly bulletin, “Rokok &
Kesehatan” is presently being published for medical
doctors/health professionals.
The Indonesia Smoking Control Society, analysed
smoking behaviour using the existing data compiled
through the Indonesia Family Life Survey (IFLS) and
the Survey on Eye, Ear-Nose and Throat Health, both
carried out during 1994 to 1996. Since both surveys
did not cover the entire 27 provinces of Indonesia, the
results of this study are of no question to represent the
Indonesia’s situation. The Hedge method was utilized
for the Meta analysis. Univariate and bivariate analysis
were run at 95% confidence level.
Working in conjunction with the Faculty of Medicine,
University of Indonesia, activities are in progress to
wards student education on tobacco and declaration
of the campus as “no smoking” zones. Reaching the
yOung with the message on tobacco, through vari
various
channels, is the priority activity of the Society. Presen
tations on tobacco or health were organised for biolOgy teacbers in Jakarta with the view to equipping them
knowledge and skill to share information on
tobacco with their students. In some instances, the
Society has reached students of several private secondary schools in Jakarta.
The study found that in 14 provinces ot Indonesia, 59%
of males aged above 10 years were current smokers,
whereas only 4.9% of females were found as current
smokers in a similar age group. Among these smokers,
13% -28% were male teenagers, and 0.6% to 1% were
female teenagers. Among the male current smokers,
the average number of cigarettes smoked was 10 per
day, as compared to 3 among the female current smokers. Tobacco mixed with cloves, cigarettes, namely
“Kreteks” (read: kreatacs) are the most popular ciga
rettes among the current smokers. The data showed
that around 81 % of male smokers and 78% of female
smokers smoked Kreteks.
To further the Society’s aim of reaching out to vulnerable groups, it has opened a new office in eastern Jakarta,
For further information please contact:
Dr Tjandra Yoga Aditama,
“Lembaga Menanggulangi Masalah Morokok (LM3)”
JI. Cempaka Putih Timur 12
Jakarta 10510-Indonesia
Fax : 62 21 4205236
E-mail: doctjand@link.net.id
Females started to smoke cigarettes at an earlier age
as compared to the males. The study found that the
11
PERSPECTIVE
THE CASE AGAINST GUTKA IN INDIA
What does one do with a newly introduced food product, industrially manufactured and
commercially marketed on a large scale, conclusively shown to cause serious disease? The
obvious answer would be - ban it. In reality, however, that is easier said than done.
Dr Prakash Gupta, of the Tata Institute of Fundamental Research, Mumbai, examines the
issue and comes up with some answers.
UTKA is a generic name for a product that
contains
tobacco,
areca
nut
and
several
other
substances. It is sold in powdered
or granulated form in small foil
sachets. It is chewed and sucked,
and then spat out or swallowed.
Introduced as a commercial product
less than three decades ago, gutka
is now manufactured on a very large
scale and the annual turn-over runs
into several hundred million US
dollars.
The oral use of any tobacco product
is known to cause cancer of the
mouth. Gutka also causes another
Dr. Gupta
serious disease - Oral Submucous
Fibrosis (OSF). In this disease, fibrous bands develop
in the mouth, mucosa loses its elasticity and the opening
of the mouth reduces progressively. In extreme cases,
it may reduce so much that only a straw can
pass through. This disease does not regress
and has no known cure. More
seriously, it can lead to cancer.
Oral cancer takes a long
time to develop. The
effect of gutka on
the incidence of oral
cancer is therefore not
yet apparent. OSF
among gutka users,
however, seems to deve-lop
very fast, and there have been
many reports on an evolving
epidemic. This has been confirmed
through carefully conducted
population-based epidemiological
12
studies as well.
In a recent study in Bhavnagar, Gujarat,
the use of tobacco and products
containing areca nut was assessed, and
dentists carried out oral examinations.
A total of 11,262 men and 10,590
women were interviewed. Of 5018 men
who use tobacco or areca nut, 164 were
diagnosed as suffering from OSE All
but four cases were diagnosed among
1786 individuals currently using areca
nut (RR - 75.0). Areca nut was used
mostly in mawa, a mixture of tobacco,
lime and areca nut, and 10.9% mawa
users had OSF (RR - 90.8). Incidence
of OSF as well as areca nut use was
mainly in the under 35 age group. In an
earlier study conducted in exactly the same
manner in the same district in 1967, the
prevalence of OSF was 0.16%. Thus
a substantial increase in the
prevalence of OSF, directly
attributable to the use of areca
nut products, was observed.
There is also a substantial
probability that the
incidence of oral cancer
will increase in the
future.
s
In an attempt to curb
and regulate gutka
promotion and use, a public
interest litigation was filed in a
State High Court. The Central
Committee on Food Standaids
(Contd. on page 14 )
INTERVIEW
The fact that problems related to the abuse of alcohol are increasing needs no reiteration.
It would seem that shifting political will in connivance with ineffective laws and inevitable
changes in the socio-cultural context all lead to statistics that cause alarm. Dr Hem Raj Pal,
Assistant Professor of Psychiatry at the All India Institute of Medical Sciences,
New Delhi, talks to LIFELINE about some aspects of the alcohol problem in India.
Q: What is the magnitude of alcohol - related
problems in India? Is data readily available?
In Delhi, 7.6% of
adult males have
been diagnosed
as suffering from
alcoholdependent
disorders. Among
plantation
workers in the
north-east, 1220% reported use
of alcohol, with
about 5% having a dependent use pattern. It is
interesting that as opposed to a predominantly male
drinking population in general, 28-48% of users on
plantations are women.
A: The vastness of India compounded with its
heterogeneous population makes it difficult for us to get
exact data. Besides, we do not have a national database
for consumption figures. Studies at different times and
regions are the only source of information. Even
production estimates are likely to be misleading because
of the large sector of unorganised home brewing and
country made liquor. In spite of all this, it is generally
felt that alcohol consumption is on the increase in
the country.
The national per capita consumption of absolute alcohol
is estimated to be 2 litres. If corrected against largely
abstinent women, home brewed or smuggled alcohol,
the estimate rises to about 3 to 4 litres. This assumes
further significance when the per capita consumption
of some states is reviewed.
Q: Surely all this is reason for concern?
A: Certainly. In fact, a disturbing trend that is noticed
in various studies especially from Kerala and
Karnataka is that the age for first use of alcohol has
decreased from 19 years in 1990 to about 14 years in
1996. More and more young people seem to be
consuming alcohol and alcohol use is gaining social
acceptance. A conservative estimate of dependent
users nation-wide can be set at about 3-5% of the
adult male population. If you translate this into numbers,
we have a major health problem on our hands.
Q: Could you elaborate on this?
A: States like Punjab and Haryana with 8.54 litres and
9.67 litres per person per year respectively have rates
comparable to some states in Europe. Others like
Karnataka and Kerala are catching up. Bangalore as a
city has one of the highest consumption rates - 10.5
litres per person per year. At the same time, we see
that as opposed to states with high rates there are others
which have, in principle, total prohibition. Some
indeterminate consumption occurs as a result of home
brewing.
Q: What would you rate as some of the more
serious ill-effects of consuming alcohol?
A: There are many negative consequences. Road
traffic accidents as a result of drunken driving are
estimated to be the third largest cause of morbidity
and mortality in the country. Alcohol consumption has
About 18-25% of people in Kerala, for example, mostly
males, consume alcohol regularly. Gujarat has
prohibition but 26.4% of students report alcohol use.
13
been identified as a factor in about l/3rd of all the
episodes of violence in families. The drain on finances
and consequent lack of money for important things like
education goes without saying. Hospital statistics show
an increase in morbidity and mortality related to alcohol.
Though exact data is hard to come by, case control
studies at the Regional Cancer Centre,
Thiruvananthapuram reveal alcohol as a major risk
factor in cancers of the oral cavity, larynx, oesophagus,
stomach, pancreas and liver. Gastritis, cirrhosis and
portal hypertension are also common. At the All India
Institute of Medical Sciences, New Delhi, 12-15% of
total admissions and about 35% of all diseases are
alcohol-related.
of the laws are hopelessly outdated and need to be
reframed. ‘Dry’ states like Gujarat have the provision
of issuing liquor permits on grounds of health. Till March
1997, 20037 permits were granted out of which 8,777
were ostensibly for ‘health’ reasons! So you see, laws
can exist, but implementing them in a proper manner is
another matter altogether.
Q: This may seem academic, but what needs
to be done? Does it all boil down to shared
responsibilities?
A: Well, there are a number of measures that can be
taken up. To name just a few -
Q: What is being done in terms of control
measures? What steps has the Government taken?
Steps should definitely be taken to contain availability.
This would bring into its purview positioning of sale
outlets, sale timings, customer categories and so on.
A: Article 47 of the Constitution specifically refers to
prohibition, but Government control over alcohol is
primarily a state subject. The states themselves have
varying policies with total prohibition on one hand and
free availability on the other. Some states
have experimented with prohibition and repealed it
later. Other measures restrict the sale of alcohol on
certain days, specify that it can be only sold to those
over 18, and also restrict the quantity sold. There are
laws relating to drunk and disorderly conduct in public
places and strictures against driving when drunk.
Taxes on alcohol should be high enough to deter its use
and should also be in keeping with the consumer price
index and the wholesale price index.
I also feel that some of the revenue should be used
for rehabilitation and treatment of alcohol-related
disorders.
Banning of all advertising and surrogate promotion and
placement of prominent health warnings are essential.
As far as prevention activities are concerned, we tend
to concentrate more on secondary ones. The focus
should be on primary, secondary and tertiary activities
- information, education (this includes the school
curriculum), rehabilitation, etc. Intervention by women’s
groups and environmentalists can prove very effective.
What we have to keep in mind is that trying to cleanse
a society of a harmful addiction is not one person’s job
or one agency’s job - it is a collective duty.
Q: If laws exist, why is the problem escalating?
What are the lacunae?
A: The policies relating to alcohol at the Centre and in
the States have no uniform principles - they are
haphazard and inconsistent. For a drug that has serious
health consequences, it is strange that the guiding
considerations are not that of health but revenue! Many
substantial progress. One Minister declared that the
Government could not ban gutka as areca nut farmers
would be affected. The Health Minister could only
announce that an educational campaign would be
launched against the use of gutka. The largest
manufacturer of gutka has the last word - ‘Gutka is
harmful and we do not object to a ban, but cigarettes
should be banned first.’ Need we say more?
THE CASE AGAINST GUTKA IN INDIA
(Contd. from page 12)
conducted hearings and investigations and concluded
that gutka is dangerous, and recommended an outright
ban. The gutka lobby, however, swung into action,
and since then there have only been conflicting
signals and statements from the Government, but no
14
FOCUS
WORLD NO-TOBACCO DAY 1999 ■ CESSATION
‘Leave the pack behind’
the new mother as the health of the new generation
ensures the health of society.
ETTING more smokers throughout the world
to quit is one of the keys to reducing the The benefits of quitting smoking pertain to both public
projected toll of deaths from tobacco over the and individual health. A general sense of well being
next two decades. WHO annually sponsors World No enriches one’s personal life and, in turn, contributes to
Tobacco Day to call attention to the seriousness of a healthy society. Looking beyond the realm of health
this issue. The theme for 1999, Cessation, is seen as to that of finance, it has been estimated that the health
a critical step towards improving world health. Even if care costs associated with smoking-related illnesses
only a small proportion of today’s 1.1 billion smokers result in a global net loss of US$ 200 billion per year,
were to stop, the long-term health and economic with half of these losses occurring in developing
benefits at both the individual and societal levels would countries. It therefore goes without saying that smoking
be immense. Each year, tobacco causes 3.5 million cessation efforts, by decreasing health risks in the same
deaths, that is 10,000
way
as
smoking
deaths a day. One million
HOW TO QUIT
prevention efforts, are
of these currently occur • Commit to quit: Define and decide specific motivation cost effective as well.
factor and build your desire to quit
in developing countries.
Interventions by health
The global tobacco • Choose quit date and stick to it - don’t try to gradually professionals, higher
epidemic is predicted to
stop, it won’t work.
levels of personalization
prematurely claim the
of
intervention
• Talk with your doctor and discuss strategies.
lives of some 250 million
programmes, mass reach
children and adolescents • Get rid of all tobacco-related equipment around you
programmes, quit and win
alive today, a third of • Don’t worry about dieting until you have stopped
competitions that provide
whom are in developing
a ‘unique, positive
countries. By 2020, it is • Enlist support of friends and the family
approach’ to cessation,
predicted that tobacco • Avoid situations that prompt smoking - and finally
and
self-directed
will become the leading
programmes are all
• If a parent, think of your children
cause, of death and
helping factors on the
disability, killing more
road to quitting smoking.
than 10 million people annually. Research has shown Nicotine Replacement Therapy and other
that smoking cessation greatly reduces the risk of pharmacological treatments are also aids in the
tobacco-related disease, so that most of these deaths endeavour.
are potentially preventable by intensive cessation
A successful global smoking cessation programme
interventions.
needs a multi-faceted approach. Health education,
public policy, information dissemination programmes,
Early cessation is essential for restoring good health to strong legislation - are all vital components in a
the smoker while sustaining the least health damage. comprehensive cessation effort. Motivation to quit is a
Targeting teenagers in cessation efforts is the first major component of any cessation attempt.
natural step in comprehensive smoking cessation Here educators, health care providers and family
interventions. In order to target teenagers, cessation members have a vital role to play. Globally,
materials and information appropriate to their age must comprehensive tobacco control policies
be accessible. This is an area that requires more and programmes, targeting both prevention and
attention than has been given to it so far. Cessation cessation, can help stem the growth of today’s tobacco
efforts will also be aimed at the pregnant woman and epidemic.
15
WORLD VIEW
THE TOBACCO FREE INITIATIVE A GLOBAL RESPONSE AGAINST AN INSIDIOUS ENEMY
*7 am a doctor. I believe in science and evidence. Let me state here today. Tobacco is a killer. Tobacco should not
be advertised, subsidized or glamourized. ” Speaking at the World Health Assembly in Geneva on May 13, 1998,
Dr Gro Harlem Bruntland minced no words in denouncing the use of tobacco. She said that ‘all countries need to
take strong action individually and together if their populations are to become tobacco free in the long term'. It is
clear that a concerted effort is urgently needed at all levels if there is to be a visible level of success. Reiterating that
tobacco control cannot succeed solely through the efforts of individual governments, NGOs and the media, Dr
Bruntland said that what we need is ‘an international response to an international problem'.
'W’V THO’S pioneering efforts in tobacco control
%/%/ over the last three decades and the many World
▼ ▼ Health Assembly resolutions that have been
adopted by all the Member States have
ensured much progress. Yet, according to
WHO estimates, there are currently 3.5
million deaths a year from tobacco, and the
figure is expected to rise to about 10 million
by 2030. Of these, 70% will be in developing
countries. The sheer scale of tobacco’s
impact on the global burden of disease, and
the frightening prospect for the future
without proper intervention, is often not fully
comprehended. In response to these
concerns, the WHO Director-General, Dr Gro Harlem
Bruntland, established a Cabinet project, the Tobacco-Free
Initiative (TFI), in July 1998 to co-ordinate the global
response to tobacco control. With the long term mission of
reducing tobacco consumption and smoking prevalence
firmly in mind, the TFI aims to galvanize global support,
while strengthening old partnerships and forging new ones.
It realises the importance of speeding up the process of
planning and implementation of tobacco control at all levels.
Building a global database through surveillance and
commissioning policy research, mobilizing adequate
resources and creating an effective Framework Convention
for tobacco control are also primary goals of the TFI.
The WHO Regional Office for South-East Asia has taken
the initiative seriously. The Region accounts for 25% of the
world’s population and is proving a happy hunting ground
for the tobacco industry, with tobacco markets shrinking in
the West. Eight of the ten Member countries are commercial
tobacco producers and three of them are among the world's
leading producers of tobacco. Even countries like Bhutan
and Maldives, which do not produce tobacco, have access
to the produce from their neighbours. There is a growing
increase in the prevalence of tobacco use among women
and children. Tobacco-related illness and deaths are on the
increase.
The
socio-economic,
environmental as well as health implications
are estimated to reach disastrous levels in
the next millennium. The Regional Office has,
therefore, intensified its advocacy efforts to
Member countries on control measures. Dr
Uton Muchtar Rafei, Regional Director,
WHO South-East Asia Region, has
underscored his personal commitment to
tobacco control. He has pointed out that the
serious erosion of health gains through
premature deaths attributable to tobacco and the rapidly
emerging burden of noncommunicable diseases in the
Region are a cause for grave concern. He has communicated
this concern to Heads of Government and Heads of State at
various regional forums. The Regional Committee, the highest
policy making body, will discuss the problem at its 52nd
session in Bangladesh this year. It is hoped that the outcome
of the discussions would provide further impetus to tobacco
control efforts in the Region.
Request for Contributions from the Region
Help to make this newsletter truly representative of
the efforts of all countries of the Region. We invite
articles and features on tobacco and alcohol
prevention and control efforts, suitably illustrated with
colour or black-and-white photographs, from all our
readers.The contribution, not exceeding 1000 words,
should be written in easy-to-read English.
The deadline for the next issue dated October, 1999
is end August, 1999. Please mark all contributions
to the Regional Advisor, Health Promotion & Health
Education, at the address given below.__________
Lifeline is a quarterly newsletter for private circulation only. The material used in this newsletter may not always
reflect WHO policy.
For free subscriptions please write to Lifeline. Regional Advisor, Health Promotion and Education, World Health
Organization,
Regional Office for South-East Asia, Indraprastha Estate, New Delhi - 110002, India.
(Tel. : 3317804 to 3317823, Fax: 91-3318607, 3327972, e-mail: martha@who.ernet.in)
Editor : Martha R. Osei
Editorial Board : Harsharan B.K. Pandey, Candy M. Longmire. J. Tuli, Jai P. Narain.
WORLD HEALTH ORGANIZATION
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Press Release WHA/14
24 May 1999
WORLD HEALTH ASSEMBLY PAVES WAY FOR FRAMEWORK
CONVENTION ON TOBACCO CONTROL
Assembly also approves delay in destruction of smallpox virus, Revised
Drug Strategy and support for Roll Back Malaria
The World Health Assembly (WHA), the governing body of the World Health
Organization (WHO), today paved the way for multilateral negotiations to begin on a set of
rules and regulations that will govern the global rise and spread of tobacco and tobacco
products in the next century.
The 191-member WHA unanimously backed a resolution calling for work to begin
on the Framework Convention on Tobacco Control (FCTC) - a new legal instrument that
will address issues as diverse as tobacco advertising and promotion, agricultural
diversification, smuggling, taxes and subsidies.
A record 50 nations took the floor to pledge financial and political support for the
Convention. The list included the five permanent members of the United Nations Security
Council, major tobacco growers and exporters as well as several countries in the
developing and developed world which face the brunt of the tobacco industry’s marketing
and promotion pitch.
This is the first time in its 50-year history that WHO is exercising its constitutional
mandate to negotiate a Convention. When ready, the FCTC will be the world’s first global
tobacco control treaty. ‘’It seems only right that we focus on tobacco - at the turn of a
century packed with achievements in science and medicine, tobacco stands out as an
area of appalling neglect,” said WHO Director-General Dr Gro Harlem Brundtland.
A FCTC working group will soon begin work on proposed draft elements of the
FCTC, thereby paving the road for formal negotiations to commence in about one year's
WHITSBIS99H
Press Release WHO/14
Page 2
time. WHO and its Member States plan to have the Convention process completed by
2003, after which it will be open for ratification.
Tobacco kills 4 million people per year. The Tobacco Free Initiative (TFI), WHO’s
tobacco control programme, estimates that if unchecked, this silent epidemic could kill
10 million people per year in the first quarter of the next century, over 70% of them in the
developing world.
WHO hopes to reframe the tobacco issues in a such a way as to show that far from,
and in addition to, being a debilitating personal habit, tobacco contributes to a public health
disaster exacerbated by tobacco industry practices that seek new markets and newer
victims for a product that addicts before it kills. TFI officials say they hope their work will
contribute to increased popular understanding and demands for comprehensive
government regulation of tobacco.
The FCTC’s benefits to WHO’s Member States are many. The most significant one
is that with the Convention as a pathfinder and co-ordination vehicle countries can
contribute, incrementally, to the international legal instrument and incorporate the agreed
norms into their national legislation. "Tobacco is a global problem. The tobacco industry
acts as a global force - countries need to act together to counter this threat to public
health,” said Dr Derek Yach, head of TFI.
The process of developing and adopting the FCTC and related protocols will help
mobilize national and international technical and financial support for tobacco control, raise
global awareness about the unnecessary burden of disease brought about by tobacco use
and spread and hold up mirrors to the tobacco industry’s practices.
Smallpox, Revised Drug Strategy, Roll Back Malaria
In its plenary session on 24 May, the WHA also gave final approval to three draft
resolutions which WHA committees had passed late last week.
The WHA voted to delay destruction of the remaining known stocks of smallpox
virus, committing to review the situation by 2002 at the latest (see Press Release WHA/11
for more details).
The Revised Drug Strategy also got the green light from the WHA. Thorny issues
related top trade and pharmaceuticals drew intense focus, although there was broad
consensus that access to essential drugs, now denied to a third of the world’s population,
had to be increased. In another resolution, the WHA approved WHO’s new programme for
combating malaria, Roll Back Malaria.
For further information please contact Gregory Hartl, Health Communications and Public Relations,
WHO, Geneva, telephone: (41 22) 791 4458, fax: 41 22 791 4858. E-mail: hartlg@who.ch All WHO Press
Releases, Fact Sheets and Features can be obtained on Internet on the WHO home page
http://www.who.ch
SocSaINEEDS
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Research.Training. Consultancy, and Networking.
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Uc.czr & Scmtccion, Infcrn-.ction d Ccmrr.ur.iccccr., UJcrKsrocs Q Serrjr.crs
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Dr. Rufaro Chataro
WHO Country Representative
Box 45335
NAIROBI
\\ru7
-J 4 cfy r
. T -T o
RE: MEETING OF TOBACCO GROWERS AND WHO
Our organisation has been actively involved in campaign against Tobacco production and
smokinu in the country for the last four (4) years, consequently our attention has been drawn
to press reports in regard to a meeting WHO had with the leaders of international Tobacco
Growers Association at WHO’s Headquarters, Geneva sometime early March, 1999 and
would like to make some comments.
(i)
(ii)
It is our belief that most of Tobacco farmers are exploited by the Tobacco companies \
especially in the developing countries (Kenya situation as an example) where most 1
farmers are poor and lowly-educated.
Tobacco growing has not improved the economy ot this country and it anything\
smoking costs for the Kenyan society could be much higher than the revenue broughtj
by Tobacco Industry.
(iii)
Tobacco companies would like to give impression that WHO should be more
concerned with the control of malaria, HIV/ALDs than Tobacco, related diseases, h
can be proved that Tobacco just like alcohol has influence^the transmission ot
HIV/AlDs. It is paradoxical and irrelevant to accept any support from Tobacco
Industry.
World health organisation should intestify its activities in Tobacco control programmes to cut
at
down the number of persons dying from Tobacco related diseases which currently stands; a.
of constraints
3000,000 annually. Tobacco control programmes are faced with a number ot
namely:
(i)
Gaps in medical and epidemiological knowledge especially better means of
identifying those at greater risk,
(ii)
Economic and political conflicts that arise from agricultural, manufacturing, and
marketing interests.
(iii)
Inadequate knowledge about smoking behaviour and effective motivational methods
P 0. Eox 2348
Kisumu. Kenya
"st Ficor Chekmula Building
Jcmo Kenyatta Highway
Tel: 254 (035 } 45379
Fax: 254 ( 035 ) 4079.
e -in a i 1: j. a s •! a@ m a i i e xc: ta. c c m
(iv)
Lack of communication and co-ordination amongst organisations,.groups and nations
concerned with the problem.
Suggested solutions to the above-mentioned constrains are:-
(i)
Extensive intercharge of expens and advice.
(ii)
Monitoring of extent of smoking and its consequences.
(iii)
Better availability and exchange of information (with reference to public
communication outlets)
(iv)
Search for development of alternative to economic needs of Tobacco-producing areas
and
(v)
Intensification of research on ail aspects of Tobacco-related problems.
We note with enthuthiasism your expressed commitment to Tobacco control activities and
hope you will involve and support small organisations as partners on the fight against
Tobacco. You will agree with us that smaller organisations like ours may not make any
impact without your support. To show the extent we have tried to network, we have enclosed
copies of letters from WHO and international Tobacco Initiative in response to our request
for financial assistance to conduct a comprehensive research on impact of Tobacco growing
in certain parts of Kenya. A copy of the article on Tobacco growing in Rangwe will give you
a clue on what happens in the area.
We do hope you will use your good office to convince FAO and or ITI to give us support.
Finally we are happy to let you know that Kenya Medical Association. Tobacco Control
Committee has recognised our commitment and has inco-operated us in their activities.
x
/
Thank vou.
z-
Congo Elisha
Programme Officer,
Health, Research and Social Welfare.
Dr. G.H. Brundtland: International Policy Conference on Children and Tobacco
»
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^<3^'1998
WOMP HIALTM OK4A.VIIAJ1OW
Page 1 of7
Office of the DirectorGeneral
Director- Ge/i eraI
UPDATED: Wed Mar 24 15:49:58 1999
Dr. Gro Harlem Brundtland
Director-General
World Health Organization
Washington, D.C.,
18 March 1999
International Policy Conference on Children and Tobacco
Ministers,
Ladies and Gentlemen,
In our struggle for a healthier world, we face as many challenges as there are diseases. Most
are difficult, some are tragic and some are exciting because we see real progress in our work.
The approach we must take towards all these challenges is one of creativity, patience and
stubborn, confident determination.
One of these challenges is unnecessary and it is man-made: the tobacco epidemic.
When I came to WHO last year, the Organization devoted 0.5 man years to tobacco related
work. In preparing to take office I went through the broad material on the global burden of
disease. I was determined to refocus WHO’s work on priority areas where our efforts could
make a real difference to the health of people around the world. I wanted solid facts to
underpin our priorities.
The evidence told a shocking story. With current smoking patterns, about 500 million people
alive today will eventually be killed by tobacco. Tobacco deaths will occur in men already
smoking, children who will become smokers, and an increasing number of women smokers.
%
What I saw was an emerging epidemic. Worldwide mortality from tobacco is likely to rise
from about 4 million deaths a year in 1998 to about 10 million a year in 2030. Ten million
deaths - that is more than the total deaths from malaria, maternal and major childhood
conditions and tuberculosis combined. Over 70 percent of these deaths will be in the
developing world. By 2020, smoking will cause about one in three of all adult deaths, up
from one in six adult deaths in 1990.
What does it mean: tobacco will cause about 150 million deaths in the first quarter of the
century and 300 million in the second quarter. Half of these deaths will occur in middle age in those between 35 and 69 - with an average loss of 20-25 years of life.
The implications are obvious. Tobacco burdens our health systems. It costs taxpayers
money. It hampers the productivity of our economies. Tobacco obviously provides economic
benefits to producers. But solid economic analysis clearly concludes that the costs of
tobacco exceed by far its estimated economic benefits.
So for me the decision was not difficult to take. WHO had to address this mounting
epidemic.
The day I took office, WHO launched its Tobacco Free Initiative. The way it works
illustrates the way we wish WHO to work in the future - making the most of our own
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Dr. G.H. Brundtland: International Policy Conference on Children and Tobacco
Page 2 of 7
resources and knowledge - and drawing heavily on the knowledge and experience of others.
These are our goals:
• to galvanize global support for evidence-based tobacco control policies and actions;
• to build new partnerships, to heighten awareness and to mobilize resources;
• to accelerate the implementation of national, regional and global strategies.
As a public health agency, we can assemble and distribute the evidence on the health
consequences of tobacco consumption. And we can work in partnership with others.
We work with UNICEF to devise strategies to reach out to children and adolescents. We
work with the World Bank to address taxation issues and to dispel the myths about the
financial benefits of tobacco. We work with the US Centers for Disease Control and
Prevention to support global surveillance of tobacco use and its consequences. We work
with the Environmental Protection Agency to reach the environmental constituencies.
%
We work with the National Institutes of Health and with similar bodies in other countries to
expand the evidence base. We work with NGOs such as Tobacco-Free Kids to strengthen
action at grass-roots level. And we work with the private sector to channel energy and
expertise from the pharmaceutical, media and entertainment industries into tobacco control
activities.
This is how WHO has shaped its tobacco related work over the last 8 months. We are aware
that it is a complex and long term objective to halt the growth in tobacco consumption. In
pursuing that goal, we seek inspiration from events like today's meeting of policy makers
from many countries.
What are the broad avenues that we must follow?
First we need to focus on individuals.
To change the trends we need to get smokers to quit and non-smokers not to pick up the
addictive habit.
Some object and say this is about freedom of choice. Is it really? Adults can choose for
themselves, if they have full access to information. But 80 percent of smokers start before
the age of 18. Kids often start at the age of 14,15,16. That is not about freedom of choice!
Civilized nations normally seek actively to protect their children against habits that have a
50 percent chance of leading to premature death.
The tobacco epidemic is a communicated disease. It is communicated through advertising,
through the example of smokers and through the smoke to which non-smokers - especially
children - are exposed. Our job is to immunize people against this epidemic.
The victims are teenagers like Mia Katandian, a fourteen year-old girl in the Philippines.
Mia's days are similar to those of millions of other teenagers around the world, living under
difficult circumstances on the very limited resources of her single mother. The reality of
never being able to afford clothes or the other things she craves she tries to make tolerable
through some heavy doses of day-dreaming, through hours of strolling through shopping
malls and through television.
Wherever Mia goes there are billboards, and whenever she watches on TV there are
commercials telling her that "happy people smoke". The rich, who drive fast cars, sit on
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Dr. G.H. Brundtland: International Policy Conference on Children and Tobacco
Page 3 of 7
white beaches with handsome partners and ride horses in the evening sun - they all smoke.
She can not afford their lifestyle, but by sitting in a cafe and holding her cigarette elegantly
the way she has seen in the ads, she can, for a short while, pretend she is one of those rich
and beautiful people.
Only her mother tells her not to smoke. But then, what better way to show a bit of adolescent
defiance than coming home with smoke on your breath?
Habits start in youth. The tobacco industry knows it, and acts accordingly. A 1990 Regional
Overview of marketing opportunities by Philip Morris Asia, makes it clear that Mia and her
fellow young are the special targets of tobacco advertisers. Here is what they say:
"Advertising and promotions should be aimed at entry level smokers to keep the franchise
young and dynamic,"
And it continues:
"Young adult promotions could help us build the king-size franchise among entry level
smokers (...) (The brand) Parliament Menthol could be a line extension to broaden appeal to
younger smokers and women."
Other documents show that the tobacco companies' definition of "young adults" is as low as
children 14 years old.
What kind of freedom of choice are we talking about? For Mia and millions of others it is
the freedom to choose rationally whether or not to take up a habit which is so harmful to
their health.
People in government, like many here today, have the power to act. Those actions, both
personal and official, will decide if tobacco shall claim new millions of victims in your
home countries. Those actions will help prevent the cost of treating hundreds of thousands
of cancer and heart disease patients from breaking the back of your health systems in the
coming decades. Those actions will see to it that children don't lose their parents
prematurely through cancer and heart diseases caused by smoking. Those actions will help
prevent teenagers from being fooled into an addiction which gives them only a 50 percent
chance of surviving middle age.
WHO will gather, analyse and disseminate evidence on tobacco use, on patterns of
consumption and paths that lead to it. That evidence will illustrate that there are many
misconceptions. Two of the most frequent ones are that tobacco is a problem of affluent
countries, and that tobacco is good economics for national treasuries strapped for cash.
One important message to drive home is that tobacco control is a global challenge.
Policymakers ask: How can we increase taxes if our neighbours keep them low? How can
we introduce stricter advertisement legislation if the message in many cases reaches us
through the satellites? How can we deal more effectively with smuggling?
For the first time WHO will make use of its right to put forward a Framework Convention
on Tobacco Control. Our Member States called for this in 1996. The Executive Board in
January responded to my proposal and now recommends the World Health Assembly to
move ahead.
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Dr. G.H. Brundtland: International Policy Conference on Children and Tobacco
Page 4 of7
The aim of this process is to pass the Convention and key protocol agreements no later than
May 2003. If a Convention is adopted and enters into force it will be the first time that a
convention approach has been applied to address a global public health problem. The
Convention will call for cooperation in achieving broadly stated goals - supplemented by
protocols which address specific issues, such as advertisement.
As the process gathers steam our determination is to help galvanize national action through
the work of the media, NGOs, and the academic and scientific communities: We need to
increase public support for truly global action.
This is to a large extent a cultural struggle. Our main battlefield on children and tobacco is
in that strange, exhilarating and often confusing landscape called adolescence. We must
enter the discotheques, the schools and the sports arenas. In many countries, cigarettes are
given out for free on the dance floors. We have to win these spaces back.
%
There is a long way to go: An agreement between a major Hollywood film producer and a
tobacco company contained the following clause:
"As we discussed, your company's cigarettes will be used in ourfilm as the product is
intended. Specifically, one of our main characters, Munro Kelly, (...) will be smoking your
cigarettes. The only slightly different use is when he offers a cigarette to Amy, the gorilla
(...), and she takes it and imitates Munro by smoking."
If we are to prevent tobacco-related deaths from tripling by 2030 to 10 million people each
year, we will have to convince our children that smoking isn't cool. Not even for gorillas.
Smoking will continue to be an issue on which every individual will have a personal
experience - of his or her personal history or that of a close relative. As we proceed with our
work we need to take advantage of this. We know that a majority of smokers would like to
leave the pack behind. We should help them - and in doing so we need to base our advice on
solid evidence.
One part of the evidence is that the one who smokes not only puts himself in danger; he also
endangers the life of the one who doesn't smoke. If the non-smoker is a child, that is
especially true. The latest research on the effect of environmental tobacco smoke on children
provides disturbing findings:
• children of smoking mothers have a much higher risk of getting lower respiratory
illnesses, such as bronchitis, croup and pneumonia;
• they are more vulnerable to ear infections;
• the symptoms of asthma and respiratory irritations, such as wheezing and coughs,
increase;
• the risk of low birth weight and intra-uterine retardation increases for babies of
mothers who smoke. Birth-weights are affected even when mothers are only exposed
to passive smoking;
• infants of mothers who smoke run almost five times the risk of sudden infant death
syndrome compared with infants of mothers who don't smoke.
• parental smoking is associated with learning difficulties, behavioural problems and
language impairment.
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Dr. G.H. Brundtland: International Policy Conference on Children and Tobacco
Page 5 of 7
Beside the individual suffering, children’s involuntary exposure to tobacco smoke has
serious economic consequences. By balancing the figures from several studies, we find that
the cost of treating afflictions related to children's exposure to tobacco runs at around $1
billion each year in the United States alone.
Still, these sad facts can be turned around. With the exception of smoking during pregnancy,
most risks are quickly reduced when parents quit. There is also strong evidence to show that
if one or both parents quit smoking, children are much less likely to begin.
The Convention of the Rights of the Child, our moral obligations, and plain, nationaleconomic logic all commit us to do our utmost to prevent millions of children and young
adults becoming victims of the tobacco epidemic.
As we look ahead - as we work out our strategy and bring together our partners, we see how
political decision-makers and legislators are crucial. We take this work forward by global
consultation and national decision-making step by step.
There are encouraging signs. Many of you who sit here today have already done a lot. WHO
will keep track of the lessons learned and make both successes and failures available.
Let me mention a few:
• Several countries in Asia have been moving towards limiting tobacco advertising. So
much, in fact, that tobacco companies have found it hard to defend sponsorship of
many of the sports events it for some years has funded.
• In Australia, the Health Minister of Victoria State leads the world in dedicating
tobacco tax to a health promotion foundation that has replaced sports sponsorship by
tobacco and stimulated community-based recreational activities.
• Canada is the first country to call for a global convention on tobacco control and it has
been a stalwart in initiating new approaches to tackle youth smoking, including an
innovative and effective media program targeting youth to quit.
• China has been building a formidable network of smoke-free schools, passing
restrictive tobacco advertising ban laws; and showing leadership in hosting the last
World Conference on Tobacco Control in 1997.
• In the Philippines, former Health Secretary and now Senator Juan Flavier has just
finished drafting one of the strongest tobacco control laws in Asia. If passed, it will
lead to a total ban on the advertising and promotion of tobacco products, and
cigarettes will only be sold to those who can prove they are 18 or older. This is
excellent news for Mia and her compatriots.
• Egypt should be commended for Sherif Omar's early research over a decade ago
showing the economic impact of tobacco in Egypt, and advocating for strong
legislative action during the 1980s.
• In France, the Evin law is one of the models of comprehensive approaches to tobacco
control. The combination of advertising bans and taxes has reduced consumption by
more than ten percent since the law came into force in 1993.
• Sri Lanka and South Africa have promulgated legislation within the last few months
to ban tobacco adverts and strengthen protection of children. We know they have done
this in the face of formidable tobacco industry pressure.
• The United Kingdom has produced a very impressive new White Paper that achieves
coherence between its domestic and international policies. The call in the White Paper
for stronger global action is what this meeting is all about!
• Zimbabwe and Minister Stamps must be congratulated for hosting the first All Africa
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Dr. G.H. Brundtland: International Policy Conference on Children and Tobacco
Page 6 of 7
Conference on Tobacco Control in 1993; for stating clearly then and more recently
that demand-reduction is a fundamental responsibility of governments; and that
special attention should be given to supporting long-term needs of tobacco growers.
• The United States is sending an important message through the recent legal cases
against the tobacco industry, not least by making available huge amounts of evidence
and information. At the Federal level, we are happy to see the advancing of tobacco
control, through regulatory and other approaches.
We have evidence to show that positive results come from concerted action on several
fronts: tobacco advertising bans, increases in taxation and a high level of public awareness.
We can sum it up in two key words: legislate and educate.
One of these elements, without the other, will not work. There must be broad support and
commitment permeating a government that wants to reduce the damage from tobacco. The
Prime Minister, the Health Ministry, the Finance Ministry and all the political leadership at
the top must be united and committed to take the battles and the back-lashes that are bound
to result from decisive anti-tobacco action.
Let me address a final issue: Tobacco production and employment. What will tobacco
control do to tobacco farmers? The questions come from the heart of the United States, from
the rural areas of Zimbabwe or from the agricultural regions in China.
We can be frank and clear: we are not attacking those who, by tradition or by lack of other
suitable crops, grow tobacco in their fields. We are not blaming those thousands who work
in tobacco plants because it is the best - or the only - steady job in their home town. We do
care about their future livelihood in our fight against tobacco.
I told the President of China when I met him a few months ago: even if our most optimistic
hopes are realized, tobacco consumption will not decline from one day to the other. We may
succeed in slowing the growth - then stabilize and hopefully turn the tide of a relentless
increase in tobacco consumption. There will be plenty of time to adapt. Tobacco control in
China is a long haul operation.
What leaders should really worry about is if the growth in tobacco consumption continues.
In addition to the daunting health burden, tobacco farmers may well ask for more land for
tobacco production. China - and any other country in the world - could use their agricultural
land for much better purposes if we are to succeed in feeding a growing world population.
Ladies and Gentlemen,
We can succeed - and meetings like this should give new inspiration. We can sum up with
the four As: Awareness, Action, Assistance and Alliances. We have to counter fiction with
fact, we have to dispel ignorance with scientific evidence and we have to tackle inertia with
the simple message that tobacco kills.
That it will kill countless young girls like Mia is the greatest tragedy of all. If this policy
conference can take us a step further forward to save her and millions like her, we will have
begun to make a difference for world health.
Thank you.
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Dr. G.H. Brundtland: International Policy Conference on Children and Tobacco
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Dr. G.H. Bru...: Ninth International Conference of Drug Regulatory Authorities (ICDRA Page 1 of 5
i
WOHLI> MIAlTM OUZAWITAntiH
Office of the DirectorGeneral
Director-Gen eral
UPDATED: Mon May 3 16:50:42 1999
Dr. Gro Harlem Brundtland
Director-General
World Health Organization
Berlin,
27 April 1999
En francais
Ninth International Conference of Drug Regulatory Authorities (ICDRA)
Keynote Address
Excellencies,
Colleagues,
Ladies and Gentlemen:
i. ■
II
The International Conference of Drug Regulatory Authorities is an important forum for
senior drug regulatory officials from all parts of the world. This Forum is of particular value
to representatives from smaller authorities with limited resources. Coming together, we can
share experiences and draw on each other.
On behalf of the World Health Organization, I wish to pay tribute to the German Ministry of
Health, to Minister Fischer and to Professor Hildebrandt, Director of the Federal Institute for
Drugs and Medical Devices and his staff for all the work that they have put into the
preparation and organization of this conference.
%
V'*.
The main responsibility of drug regulation is to safeguard the availability of good quality,
safe and effective pharmaceuticals to all citizens. This is critical to any health care system.
Access to drugs and vaccines is routine in many countries. But parallel to this we also see
the negative consequences on populations who are denied access even to the most essential
drugs. A vital part of health care is availability and rational use of essential drugs and
vaccines. WHO continues to establish and develop clear and practical norms and standards
to assist countries in the assurance of the quality and safety of drugs. This is a goal
supported and pursued by all parts of the Organization. The newly established Department
of Essential Drugs and Other Medicines is WHO's main instrument in promoting the
essential drugs concept. We are giving renewed commitment to helping countries establish
and sustain operational health care systems, of which access to essential drugs and
medicines remains a bedrock principle.
Much progress has been achieved over the years, but much remains to be done. Lack of
essential drugs, irrational use and poor drug quality remain a serious global health problem.
Let me mention just a few examples:
• Over one-third of the world's population still lacks access to essential drugs and even
the most basic diagnostic technology. In the poorest parts of Africa and Asia, this
number climbs to over 50 percent.
• Fifty to ninety percent of drugs purchased in developing countries are paid for out-ofpocket. The burden falls mainly on the poor who are not adequately protected by
health policies.
• Up to 75 percent of antibiotics are prescribed inappropriately.
• Worldwide, an average of only 50 percent of patients take their medicines correctly.
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Dr. G.H. Bru...: Ninth International Conference of Drug Regulatory Authorities (ICDRA Page 2 of 5
• Ten to twenty percent of sampled drugs fail quality control tests in many developing
countries and counterfeit medicines have been detected both in developed and
developing countries.
• The wide use of injections and the high prevalence of unsafe practices put
communities at risk of blood-borne diseases such as hepatitis B and C, and HIV.
Many of these issues will be addressed during this conference and I hope that by working
together, we will find practical and implementable solutions.
I have pointed out some of the main problems we face with regard to pharmaceuticals. They
are well known to us. But at the same time we are facing new challenges:
Increasing globalization touches almost all sectors of our lives. This has an impact on health
and includes both the availability and the development of pharmaceuticals and vaccines. We
are facing many new issues due to the pace of change and the movement towards an open
market economy, massive increases in the cost of health care provision and new innovative
treatments, privatization, and free trade. The establishment of the World Trade Organization
and the implications of WTO agreements such as Trade Related Intellectual Property Rights
(TRIPS) and Technical Barriers to Trade (TBT), increasingly sophisticated technologies and
techniques in health care, biotechnology and the revolution in information technology such
as the Internet and telemedicine, all come together and create a new and complex platform
for Governments and other actors in the field of pharmaceuticals. It is difficult for any health
care system to cope with these challenges but it is particularly difficult for countries with
limited resources. WHO will continue to play its role as an active advisor to authorities who
face these new challenges.
Today I wish to spend time on another key issue related to regulation. Speaking to this
audience, I would miss an opportunity if I did not clearly state that the time has now come
for concerted regulation of tobacco products.
In this century - a century of astounding public health gains - tobacco control stands out in
most countries as an appalling failure. Too few resources have been committed; too often
national governments have chosen soft options over effective measures.
If you think I am being too critical, consider these facts:
• More people smoke today than at any other time in human history.
• World-wide, the tobacco death rate is up - way up. As I speak, four million people are
killed each year by tobacco industry products.
• Half of all long-term smokers will be killed prematurely by tobacco industry products.
Five hundred million people alive today are likely to be killed by tobacco.
• Half of these will die in their productive middle years. This robs families of economic
support and countries of the contribution of its most experienced workforce.
But this is only the beginning. It will get worse, much worse, before it can get better.
Tobacco promotion is linked to smoking initiation. Often among the very young, initiation
leads to addiction. 80 per cent of smokers reveal that they were addicted before the age of
18. That is not freedom of choice. Addiction results in prolonged use. And tobacco use
causes avoidable, premature deaths decades later. So the focus of today’s tobacco promotion
will largely determine who will be killed by this product in 2025. And by that date, leading
experts predict, tobacco industry products will kill 10 million per year. That is almost a
tripling of today's level. Tobacco will then be the single largest contributor to the global
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Dr. G.H. Bru...: Ninth International Conference of Drug Regulatory Authorities (ICDRA Page 3 of 5
burden of disease.
And perhaps saddest of all, smoking is growing rampantly in the developing world. Nearly
all the consumption growth - and the 7 million extra deaths per year - are expected in
developing countries. With present tobacco marketing expansion in Asia, Latin America and
Africa, tobacco companies are building their customer base and in the process impeding the
economic development of the poorest nations. So without new and more vigorous and
effective interventions, those countries least capable of addressing the problem are soon to
be hit the hardest.
This is the challenge facing you in each of your countries. This is the backdrop against
which WHO has stepped up its tobacco control activities.
Part of the failure of past tobacco control stems from the incongruous way tobacco products
have been regulated.
Tobacco's selling price is often influenced through taxes. The cigarette box is marginally
controlled in many countries through mandated health warnings. And tobacco advertising is
controlled only in some countries.
But the root problem is not the cigarette package, or the price, or the advertising. The
problem is the product itself. Cigarettes are inherently dangerous products. The tobacco
companies, despite knowing this for many years, have steadfastly chosen not to remedy this,
and to press forward their sales.
It is this failure of the marketplace to solve the problem that is our invitation to step in and
make a difference.
Though this will not be easy, too often the challenges have been overstated, and too often
countries have chosen to tinker on the edges rather than attack the root cause.
One of the largest transnational tobacco companies opposes tobacco content regulation. But
this company is not unfamiliar with product regulation because it has a food products
division, and the contents of these food products are of course often regulated.
How can any of us justify that the contents of food products, made by a company, are
regulated but that the contents of cigarettes, another of its products, are not?
The tobacco companies will inevitably tell you that they are selling a simple agricultural
product -chopped-up tobacco leaves rolled into a little paper tube. This is categorically
untrue. Cigarettes are among the most highly engineered consumer products available.
The companies say that nicotine occurs naturally and inevitably in tobacco, rather like seeds
in an apple. There is evidence that nicotine delivery to the smoker may be skilfully
controlled so that the cigarette delivers a sufficient dose of nicotine to create, then maintain
addiction.
So-called "light" cigarettes deliver lower tar and nicotine to the machines, but under actual
smoking conditions smokers obtain just as much tar, just as much nicotine from "light"
brands as from regular cigarettes.
Unregulated cigarette design lets the tobacco companies fool smokers into believing they are
choosing less hazardous products. This is a misconception. Health concerns should not be
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•Dr. G.H. Bru...: Ninth International Conference of Drug Regulatory Authorities (ICDRA Page 4 of 5
exploited as a marketing opportunity.
If you still believe the industry is simply stuffing tobacco into paper tubes, not fine-tuning
nicotine delivery, consider this quote from a senior scientist working for a tobacco company,
uncovered recently from a long-hidden document. In 1972, he said:
"The cigarette should not be construed as a product but a package.
The product is nicotine. Think of the cigarette pack as a storage
container for a day's supply of nicotine. Think of the cigarette as a
dispenser for a dose unit of nicotine. Think of a puff of smoke as
the vehicle of nicotine."
What can be said about the way forward from here?
We know the status quo is not an option. Too many lives will be lost; too much economic
potential will be wasted if we avoid our responsibilities.
We know that the global nature of the problem will require partnership between national
governments, between governments and international agencies, and between the public and
private sectors.
WHO's prime contribution to international tobacco regulation will come through the
Framework Convention on Tobacco Control (FCTC), the world's first global convention on
tobacco control. That effort is ongoing, but the Convention will not be a full solution to the
problem. The treaty will only be effective if it works in conjunction with and builds upon
sound domestic interventions.
You may be wondering how the problem of tobacco smoking relates to your work as drug
regulators. I am fully aware of the business you are in - regulating medical or pharmaceutical
products. But there are a few reasons why we thought you should spend some time
discussing tobacco at this forum.
First, one of your main responsibilities is to regulate drugs to protect the health of
consumers. In order to protect the health of consumers, governments have the general
responsibility of restricting the distribution of dangerous products. This responsibility
usually covers pharmaceutical products as well as toxic chemicals and addictive drugs, and
is often given to drug regulatory authorities.
Drug regulation is also needed to promote health. Marketing of pharmaceutical products
should be regulated so as to ensure not only the safety, but the efficacy of the product. This
principle should apply to nicotine replacement therapies in the same way as for other
medicines. Many drug regulatory authorities are already assessing the efficacy and safety of
nicotine replacement therapies. It would seem that more drug regulators will be asked to do
the same in the future.
Furthermore, drug regulatory authorities are often consulted during discussions on access to
drugs. For example, whether the drug should be included under health insurance schemes, or
debating who should be authorized to prescribe or distribute the drug, including selfmedication. Thus, there are a number of technical questions drug regulatory authorities
would have to consider in connection with smoking reduction. All this would support the
initiation of a serious discussion on tobacco at this forum.
In my view, in the mid-term, three things need to happen:
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•Dr. G.H. Bru...: Ninth International Conference of Drug Regulatory Authorities (ICDRA Page 5 of 5
It
1. Experts from various countries should meet to determine our present knowledge about
tobacco products; to set a short term research agenda to fill the knowledge gaps; and
to chart the technical details of this essential change in course. I will commit WHO to
convening such a meeting with many of you by the end of the year.
2. Your governments need to take action at home. The legal framework to regulate
tobacco product content and design should be set in place. Then those matters for
which existing knowledge is sufficient should be addressed. For example, cherry
flavoured chewing tobacco is sold in several countries. What more do we possibly
need to know to decide that fruit or candy-flavoured tobacco should not be sold? The
answer is simple - nothing.
3. Together we must translate national successes into international gains. Governments
must push for the inclusion of effective tobacco content and design controls in the
protocols to the Framework Convention on Tobacco Control. Together we can
accomplish this, but it is the Member States of WHO that must be driving the process.
Hopefully with the enthusiastic support of NGOs and with society, we will be able to
keep up the momentum.
Together we can do what the tobacco industry has chosen not to do. Together we can reverse
the trends of what is developing into a major pandemic. Let's start that work here, today.
Thank you.
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pH' 3
MEDIA ALERT
World No-Tobacco Day (31 May 1999)
Press Release (embargoed until 27 May): TO FOLLOW
Plus: Press Conference
Where:
Geneva, Switzerland, Palais des Nations, Salle de Presse III
When:
27 May 1999, 14h00
What:
Winner of Director-General’s “Tobacco Free World Prize”
announced
Who:
Winner is a major international figure in the fight against
Tobacco
Dr Derek Yach, Programme Manager of WHO’s Tobacco
Free Initiative, will also be available to answer questions on
this year’s World No-Tobacco Day theme: cessation
For further information, journalists can 1) contact Gregory Hartl, Health Communications and Public
Relations, WHO, Geneva. Telephone (41 22) 791 4458. Fax (41 22) 791 4858. Email: hartlg@who.int,
2) consult the World No-Tobacco Day advisory kit or the Tobacco Free Initiative’s homepage:
http://www.who.int/toh
All WHO Press Releases, Fact Sheets and Features as well as other information on this subject can be
obtained on Internet on the WHO home page http://www.who.int/
Message
r
from Dr Gro Harlem Brundtland,Director-General of the
World Health Organization, for World No-Tobacco Day
Giving up smoking is not easy. We know that nicotine is powerfully addictive, and all of
us know people who have tried to give up smoking, only to find themselves drawn back
to it a few months later.
This is a challenge for us all, and we have to rise to it because we know that getting more
smokers to quit is the key to reducing the projected tobacco-related death toll over the next
two decades. A recent survey in a large developing country revealed that two-thirds of
smokers mistakenly believe that smoking does little or no harm; few are interested in quitting,
and fewer still have successfully quit. At present, most smokers who do successfully give up
do so without formal help. But we need to greatly increase rates of successful quitting.
Today we know that successful and cost-effective treatments exist. Nicotine replacement
medicines such as nicotine gum, patches, nasal spray and inhalers as well as non-nicotine
medicines such as bupropion can double people’s chances of succeeding.
These need to be more widely available, but the cost also needs to be reduced to bring
them within the reach of smokers everywhere. The good news is that there are real
health gains to be made from stopping at any age. Those who give up in their early 30s
enjoy a life expectancy similar to people who never smoked. I therefore invite all
smokers to take a giant step towards better health and “leave the pack behind”.
X WORID HEALTH OJGAN
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1211 GENEVA 27 SWITZERLAND - TELEPHONE: 791.21.11 - CABLES: UNISANTE-GENEVE - TELEX: 415.416 - FAX: 791.07.46 - E-MAIL: inf ©who.int
Fact Sheet No 221
April 1999
TOBACCO - HEALTH FACTS
The truth is that one out of every two long-term smokers will ultimately be killed by
tobacco. In developed countries, half will be killed in old age, after age seventy, but the
other half will be killed in middle age, before age seventy, and those who die from smoking
before age seventy will lose more than 20 years of life expectancy.
The truth is that four million people die yearly from tobacco-related diseases, one
death every eight seconds. If current trends continue, WHO estimates that the toll will rise
to ten million by 2030, one death every three seconds. Tobacco is fast becoming a greater
cause of death and disability than any single disease.
It doesn't have to be that way. WHO has decided to focus attention and resources
on tobacco use, to try to prevent at least some of these predicted deaths, and to prevent
hundreds of millions to more in the decades to come after 2030.
How many deaths?
Tobacco is a silent killer. Peaks in tobacco mortality reflect peaks in tobacco
consumption three to four decades earlier. Current smoking mortality is the result of past
lifetimes of tobacco consumption.
•
•
•
•
•
From 1950 to 2000, tobacco will have killed more than 60 million people in developed
countries alone, more than died in World War II.
If current trends continue, tobacco will kill more than 100 million people in the first two
decades of the 21st century.
If current trends continue, 500 million people alive today will be killed by tobacco.
Of the 300 million Chinese men now aged 0-29, at least 100 million will eventually be
killed by tobacco. Half the deaths will be among those aged 35-69.
In the Former Socialist Economies (FSE), around 14% of all deaths were traced to
tobacco use in 1990. By 2020, this figure is slated to rise to 22%. And smoking is the
I
Fact Sheet No 221
Page 2
major risk factor responsible for a predicted 56% increase in male deaths from chronic
diseases in FSE countries from 1990 to 2020.
How much illness?
•
•
•
•
Tobacco is a known or probable cause of some 25 different diseases. For some, like
lung cancer, bronchitis and emphysema, it is the major cause.
Other people’s tobacco smoke contains essentially all of the same carcinogens and
toxic agents that are inhaled by the smoker. Other people’s tobacco smoke is harmful
to non-smokers because it causes lung cancer and other diseases, and aggravates
allergies and asthma.
Tobacco consumption has been explicitly linked to high incidence and gravity of
cardiac disease.
Maternal smoking is associated with a higher risk of miscarriage, lower birthweight of
babies and inhibited child development. Parental smoking is also a factor in sudden
infant death syndrome and is associated with higher rates of respiratory illnesses,
including bronchitis, colds and pneumonia in children.
How many smokers?
•
•
•
WHO estimated that there were 1.1 billion smokers in the world at the beginning of the
1990s, 300 million in developed countries and 800 million in developing countries.
About one-third of the world’s adults were smokers at the beginning of this decade, and
there is little sign that this proportion has changed substantially since.
At the beginning of the 1990s, 47% of men and 12% of women were smokers. In
developing countries, it was estimated that 48% of men and 7% of women were
smokers, while in developed countries, 42% of men and 24% of women were smokers.
Tobacco use among adolescents remains stubbornly persistent. Smoking prevalence
among adolescents rose in the 1990s in several developed countries . While new
markets are being opened by tobacco industry actions, old markets have not been
closed - tobacco is a global threat.
Tobacco and smoke concern us all, smokers and non-smokers alike. Tobacco is
everybody’s problem. It is a major public health issue that demands urgent action
now.
For further information, journalists can contact WHO's Office of Public Information, Geneva.
Telephone (41 22) 791 2584. Fax (41 22) 791 4858. E-Mail: info@who.ch
All WHO Press Releases, Fact Sheets and Features as well as other information on this subject can
be obtained on Internet on the WHO home page http://www.who.ch/
WORLD HEAITH 0JGANIZATB0N
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FACT SHEET
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1211 GENEVA 27 SWITZERLAND - TELEPHONE: 791.21.11- CABLES: UNISANTE-GENEVE - TELEX: 415.416 - FAX: 791.07.46 - E-MAIL: inf @who.int
Fact Sheet No 222
April 1999
TOBACCO DEPENDENCE
The worldwide epidemic of tobacco-related disease and death continues to worsen as
tobacco use spreads. Millions of lives could be saved with effective treatment for tobacco
dependence. However, such treatment is currently unavailable for many tobacco users
throughout the world. For this reason, the World Health Organization, in preparation for
World No-Tobacco Day 1999 (May 31), offers the following information and
recommendations to governments, organizations, health-care professionals, and tobacco
users and non-users worldwide.
About Tobacco and Treatment
•
Tobacco use is widespread. At least one-third of the global adult population, or 1.1
billion people, use tobacco. Although overall tobacco use is decreasing in many
developed countries, it is increasing in most developing countries. An estimated 48% of
men and 7% of women in developing countries smoke; in industrialized countries, 42%
of men and 24% of women smoke, representing a marked increase among women.
Tobacco use is a paediatric epidemic, as well. Most tobacco use starts during
childhood and adolescence.
•
Tobacco kills. A long-term tobacco user has a 50% chance of dying prematurely from
tobacco-caused disease. Each year, tobacco causes some 4 million premature deaths,
with 1 million of these occurring in countries that can least afford the health-care
burden. This epidemic is predicted to kill 250 million children and adolescents who are
alive today, a third of whom live in developing countries. By the year 2030, tobacco
likely will be the world’s leading cause of death and disability, killing more than 10
million people annually and claiming more lives than HIV, tuberculosis, maternal
mortality, motor vehicle accidents, suicide, and homicide combined.
•
Tobacco products are highly addictive. Because tobacco products are carefully
designed to undermine efforts to quit using them, quitting is not simply a matter of
choice for the majority of tobacco users. Instead, it involves a struggle to overcome an
WHO
Fact Sheet No 222
Page 2
addiction. Tobacco use typically is woven into everyday life, and can be physiologically,
psychologically, and socially reinforcing. Many factors combine with tobacco's addictive
capacity to make quitting difficult, including media depictions and cultural and societal
acceptance of tobacco use.
•
Quitting tobacco at any point in life provides both immediate benefits and
substantial long-term benefits to health. No amount of tobacco use is safe.
Abstinence from tobacco products and freedom from exposure to second-hand smoke
are necessary for maximizing health and minimizing risk. Effective treatment for
tobacco dependence can significantly improve overall public health within only a few
years.
•
The currently available, proven treatment methods work. Hundreds of controlled
scientific studies have demonstrated that treatment can help tobacco users achieve
permanent abstinence. Effective treatment can involve a variety of methods, such as a
combination of behavioural treatment and pharmacotherapy (nicotine replacement and
non-nicotine medications). Population-based methods such as telephone helplines and
national and international tobacco-free days also can help deliver treatment.
Implementing Treatment
1. Make Treatment a Priority. Governments should rank treatment as an important
public-health priority.
2. Make Treatment Available. Health-care systems should offer practical interventions to
all tobacco users, regardless of economic level, age, and sex. This effort includes
preventing and treating tobacco use in children and adolescents, reducing family
exposure to tobacco, and providing treatment medications when appropriate. This
process is facilitated by incorporating tobacco dependence treatment into drug abuse
treatment, reproductive and maternal-child services, and other programs.
3. Assess Tobacco Use and Offer Treatment. Health-care providers should assess and
document tobacco use and should provide treatment as an essential part of quality
health care. Health-care providers should assume responsibility for learning about
tobacco use and treatment, and for providing proven interventions. Providers,
educators, and community leaders should take advantage of teachable moments and
opportunities for prevention and intervention.
4. Health-care professionals should set an example for their peers and patients by
quitting tobacco use. Governments and education systems can help this process by
funding treatment and education programs for health professionals in training.
5. Fund Effective Treatment. Governments and health care organizations should fund
treatment based on methods that have been demonstrated to be effective, and should
make treatment widely available. Increasing the institutional and human capacity for
providing this service involves training health-care workers to deliver treatment,
implementing curriculum for students in the health professions, developing resource
centres, encouraging the creation and maintenance of centres of excellence in treating
tobacco dependence, and reducing the barriers between tobacco users and treatment.
Fact Sheet No 222
Page 3
6. Motivate Tobacco Users. Governments, health providers, and community groups
share a responsibility for motivating tobacco users to quit and remain abstinent. They
should educate the public about the health risks of tobacco use, encourage tobacco
users to seek treatment, and help make treatment available, affordable, and
accessible.
7. Monitor and Regulate Tobacco. Governments should monitor and report on tobacco
use, and should tax and regulate the sale and marketing of tobacco products. These
efforts reduce initiation of tobacco use and help fund effective treatments. Responsible
regulation of tobacco products reduces tobacco use and limits risk. Regulatory
authorities should prohibit marketing strategies that give false reassurances about
minimized health risks and divert attention from quitting. Additionally, all possible steps
should be taken to reduce the harmfulness of tobacco products. Governments should
collaborate to provide meaningful and accurate ratings of nicotine and other chemicals
in tobacco products, and to reduce the toxicity and addictiveness of those products.
Treatment medications should be at least as accessible as tobacco products.
8. Develop New Treatments. Investing in the science and technology of treatment
improves the efficacy of treatment for those in diverse populations and under-served
groups. Effective treatments should be developed for groups for whom treatment has
not been available, such as children and adolescents.
Universal application of all of these measures is the most effective approach to
tobacco treatment. The current escalation in tobacco use and in tobacco-related death and
disease can only be reversed by investment in comprehensive tobacco control, which
includes treatment for tobacco dependence. Governments, health-care and education
systems, community and religious groups, as well as news and entertainment media
should collaborate in promoting tobacco treatment.
World No-Tobacco Day on May 31, 1999, provides the opportunity for governments,
health-professional bodies, and the media to join with WHO in committing themselves to
take local, national, and global action that could bend the trend of the tobacco epidemic.
• (This statement, which is based upon the best available scientific information, was
written by a group of experts from developed and developing countries hosted by the
Mayo Clinic Nicotine Dependence Center and prepared for WHO to disseminate worldwide
prior to 1999 World No-Tobacco Day. A full report will be available later in 1999; see
http://www.who.orgj
For further information, journalists can contact WHO’s Office of Public Information, Geneva.
Telephone (41 22) 791 2584. Fax (41 22) 791 4858. E-Mail: info@who.ch
All WHO Press Releases, Fact Sheets and Features as well as other information on this subject can
be obtained on Internet on the WHO home page http://www.who.ch/
1 WORLB HEAIIH 0 R G A NIZ A KO N
FACT SHEET
WEBSITE
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Fact Sheet No 223
April 1999
TOBACCO - SUPPORTING THE TOBACCO INDUSTRY IS BAD
ECONOMICS
Tobacco not only kills people, it also saps national treasuries. Just as there are no safe
levels of tobacco consumption, there are no safe investments in tobacco. The economic impact of
tobacco has been analyzed in many countries in recent years. Studies from Brazil, China, South
Africa and Switzerland complement earlier analyses done in Canada, the United Kingdom and the
United States. Their combined message is unequivocal - the alleged economic benefits of tobacco
are illusory and misleading.
The devil is in the detail. Tobacco has large, direct and intangible costs associated with it costs that often not taken into account when tobacco’s virtues are extolled. Rarely do those who
argue for continuing investment in tobacco take account of the real economic effect of declines in
the tobacco industry. Most serious analyses of all the economic effects show that a decline in the
tobacco industry would not result in less employment. In fact, as employment in the tobacco sector
decreases, overall employment may stay the same or even increase. Simply put, as one section of
the economy declines, others open up. A recent study (R. van der Merwe, The Economics of
Tobacco Control in South Africa, 1998) concluded:
“The results presented indicate unequivocally that a cessation of cigarette purchasing
would lead to significant net increases in South African output and employment”
A World Bank study entitled “The Economic Costs and Benefits of Investing in Tobacco”
(March 1993) has estimated that the use of tobacco results in a global net loss ofUS$200 billion
per year, with half of these losses occurring in the developing world. This cost does not reflect loss
due to reduced quality of life of smokers and their families. The same study also estimated that
smoking prevention is among the most cost-effective of all health interventions.
•
In a developing country with a per capita gross domestic product of US$ 2000, effective
smoking prevention costs approximately US$20 to US$40 per year of life gained.
On the other hand, lung cancer treatment, which can prolong the lives of only about 10% of
affected people, would cost US$ 18 000 per year of life gained.
For further information, journalists can contact WHO’s Office of Public Information, Geneva.
Telephone (41 22) 791 2584. Fax (41 22) 791 4858. E-Mail: info@who.ch All WHO Press Releases, Fact
Sheets and Features as well as other information on this subject can be obtained on Internet on the WHO
home page http://www.who.ch/
WHO PRESS OFFICE
WORLD HEALTH ORGANIZATION
FACT SHEET
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Fact Sheet No 224
April 1999
TOBACCO - WHAT GOVERNMENTS CAN DO - LEGISLATE
AND EDUCATE
The spectacular rise and spread of tobacco consumption world-wide is a challenge
and opportunity for the Member States of the World Health Organization. Through national
policies, governments have a key role to play in controlling tobacco as effectively as
possible.
WHO recommends comprehensive tobacco control strategies, with strong
emphasis on legislation and education. Reducing tobacco’s harmful effects requires
governments to legislate and educate. There is a need for urgent national and international
action to restrict the spread of tobacco use.
Tobacco kills four million people a year, one death every eight seconds. If current
trends remain unchecked, tobacco will also eventually kill 250 million children alive today.
This death toll is avoidable Tobacco control must come from all sectors of society, from
economic, health and social sectors.
Effective policies and interventions can make a real difference to tobacco use and
associated health outcomes. The combined impact of legislation, increased tax and
comprehensive community-based strategies has steadily decreased tobacco consumption
in many developed countries. Early indications from developing countries that have
adopted a similar mix of interventions suggest that they too will be effective.
Examples of successful legislation can be found: New Zealand adopted
comprehensive tobacco control policies in 1990. By 1996 tobacco consumption per capita
among young adults (15+) had dropped by 21%. Thailand introduced comprehensive
tobacco control policies in 1992. Smoking prevalence among young Thai adults aged 1519 dropped for 12.1% to 9.5%, a decline of over one-fifth. Thailand also registered
substantial decreases in adult smoking prevalence from 1991 to 1996.
" PRESS flFUCE
Fact Sheet No 224
Page 2
WHO recommends some key actions that governments could undertake to create
comprehensive national tobacco control programmes:
•
Legislate:
Ban all tobacco advertising and promotion
Ban sales to children
Require effective health warnings on all tobacco products
Require detailed reporting of constituents of tobacco and tobacco smoke
Regulate tobacco products
Protect people from involuntary exposure to tobacco smoke by establishing smokefree public places and workplaces
•
Bring tobacco smuggling under control through stricter law enforcement and
improved international co-operation
•
Increase the price of all tobacco products beyond inflation; use part of the revenue
for tobacco control, and part to promote economic alternatives to tobacco growing and
manufacturing
Educate:
• Invest in health education and promotion
• Provide tobacco use cessation programmes
• Support media involvement in the need for tobacco control, the availability of policies
that work and the role of the tobacco industry in thwarting implementation of effective
tobacco control policies
• Counter tobacco industry misinformation campaigns by telling the truth about tobacco
• Ensure adequate institutional support for tobacco control capacity building, applied
research, routine surveillance and programme evaluation
For further information, journalists can contact WHO’s Office of Public Information, Geneva.
Telephone (41 22) 791 2584. Fax (41 22) 791 4858. E-Mail: info@who.ch
All WHO Press Releases, Fact Sheets and Features as well as other information on this subject can
be obtained on Internet on the WHO home page http://www.who.ch/
f
\ WOBEB HEAETH ORGANUMJ^H
1
FEATURE
3
WEBSITE
www.who.int
1211 GENEVA 27 SWITZERLAND - TELEPHONE: 791.21.11- CABLES: UNISANTE-GENEVE - TELEX: 415.416 - FAX: 791.07.46 - E-MAIL: inf @who.int
Feature No 192
March 1999
IMAGES THAT SPEAK: WORLD-RENOWNED
PHOTOGRAPHER BACKS GLOBAL FIGHT AGAINST
TOBACCO
He launched a campaign in Tokyo, a concept in New York and New
Delhi. The tobacco industry was swift in spotting his talent. He put his talent to
work to sell tobacco wrapped in multi-colour dreams. Thanks to his campaign,
a company saw its sales go up by 28% in one market in six months. Others
rushed in with offers. RJR, Phillip Morris, British American Tobacco
clamoured for his attention. The image was the message. A two-pack per day
smoker himself in those heady days, he thought this was art and life joining
hands to celebrate.
There are tears in his eyes today as Ashvin Gatha looks back on the
tobacco campaigns he launched and helped design. “I thought I was selling a
simple cigarette - little did I know that I was helping sell a product that kills
people,” says this Indian-born photographer. “I want to be able to fight
alongside those who are exposing the tobacco industry for what it really does
- marketing to children, selling a drug that is addictive and fooling people into
believing they can quit when they want,” Gatha says.
People underestimate the power of images, says this amiable
photographer who has designed the World Health Organization’s (WHO’s)
image for World No Tobacco Day, 1999. It is a white marble ashtray on which
is poised a bright red orchid. Life and flower, instead of ash and death says
Gatha talking about his concept to back WHO’s pitch this year for smoking
cessation. The choice of a red flower is no accident. Reminiscent of a famous
tobacco brand, the photographer wants to turn the power of colours and
images on those very people in the tobacco industry whose mission it is to sell
10 PRESS OFFICE
I
poisoned dreams. If he could pour profits of up to 28% into their coffers, he
can also do the reverse. Gatha’s eyes twinkle.
He has come a long way in more ways than one. Orphaned at one,
Gatha grew up on the streets of Mumbai (Bombay) until an uncle living in
Singapore rescued him at the age of 14 giving the illiterate child a home,
schooling. Gatha borrowed a camera from his adoptive brother and his first
picture topped a photography competition run by the Straits Times in
Singapore. A career was born.
Living colour is splashed across all of Gatha’s photographs, from the
streets of India to the marshes of his wife’s native Switzerland, from the heady
heights of New York to the industrial products of multinational companies the
pictures tell stories words can’t. The orchid on the ashtray tells a story about
WHO’s public health campaign in much the same way - gently but firmly.
Gatha is the first to concede that it is not going to be easy taking on the
tobacco industry that pours millions every year into crafting its image. But
again, he is no stranger to adversity and opposition. When the adolescent
Gatha told his adoptive family he wanted to be a photographer and not an
office clerk, he was scorned. He had to wait till he was 23 to get his own
camera. Before that he was bitten by the New York bug that grips most artists
rearing to go. His family thought otherwise and packed him off to Mumbai’s
film industry. The only words of advice his uncle gave him were “there’s
always room at the top - remember that after sunset there is always sunrise”.
Unimpressed with the hierarchical and political nature of the film
industry at that time, he quickly opted out and, with not a rupee in his pockets,
went to live at the end in the Mumbai railway station, on bench no 4, platform
no 2. Greasing the palm of the police with 1 rupee for the privilege of sleeping
on the bench each night, and occasionally sharing the meals of a ticket
controller, Jashwan Singh, Ashvin began earning a pocketful of rupees by
photographing restaurant patrons. Disheartened and humiliated by the job, he
was complaining one evening to Singh, telling him how he dreamt of
becoming chief photographer in a magazine, when someone from the table
next door tapped him on the shoulder. It was the opportunity Gatha had
dreamed of, and his first fashion spread in Eve’s Weekly made the magazine
sell out.
New York still beckoned and Gatha took the plunge and flew to the
golden apple with eight dollars and a return ticket in his bags. However,
Gatha’s luck travelled with him on the plane to New York where he sat next to
an art director, Toni Palladino, who gave him his footstep to international
fame.
Within a week of arriving in New York, Gatha had completed the “Daily
News” campaign and earned himself $11,000. The tobacco industry turned its
expert eye on Gatha and throughout the 70s and 80s, Gatha developed
images to help sell cigarettes. “The only thing I can say, today,” says Gatha in
defence, "is that not once did I develop a campaign targeting teenagers or
children. That always remained a moral principle. As adults we can choose
what we do with our bodies and our lives, but youngsters must be protected.”
Gatha has seen the innards of the tobacco industry, including visiting
factories and production centres normally out of bounds. “The most shocking
experience was in a tobacco plant in Pakistan, near Peshawar - the place was
thick with tobacco dust. The ventilation was installed but did not work. The
poor workers had no protection and wore only cloth rags. I was sick as a dog
and had to rush out to vomit,” Gatha says.
So why did Ashvin Gatha quit smoking and change sides? “I was in the
Far East in 1991. Smoking about two packs a day and walking down these
polluted streets with carbon monoxide, lead and filth and I thought to myself I don’t need to poison myself anymore. So on August 1, the date that the
Swiss confederation was founded, I quit. From two packs to zero.”
The “quitting” didn't stop there. Gatha then began to reflect on what
cigarettes actually are, how they work and how they are sold. “In today’s
society we are bombarded by the media, not given time to think for ourselves.
Cigarettes are like a drug, a hypodermic needle and are a defiance of
individual freedom. We purchase the dreams that the cigarette companies
churn out. Never mind that we are killing ourselves in the process,” sighs
Gatha.
This is the year that WHO’s campaign on cessation succinctly summed
up by Gatha through his orchid and the ashtray image will encourage people
to “leave the pack behind.”
For further information, journalists can contact WHO’s Office of Public Information, Geneva.
Telephone (41 22) 791 2584. Fax (41 22) 791 4858. E-Mail: info@who.ch
All WHO Press Releases, Fact Sheets and Features as well as other information on
this subject can be obtained on Internet on the WHO home page http://www.who.ch/
World Health Organization
Tobacco Free Initiative
The FCTC is no ordinary convention -It is potentially a Public Health Movement
The spectacular rise and spread of tobacco consumption around the world is a challenge and
an opportunity for the World Health Organization. The challenge comes in seeking global
solutions for a problem that cuts across national boundaries, cultures, societies and socio
economic strata. The unique and massive public health impact of tobacco provides the WHO
an opportunity to propose to the world a first comprehensive response to deal with the silent
epidemic as the tobacco menace has often been called. The Tobacco Free Initiative (TFI) has
begun preliminary work in this direction.
The FCTC’s benefits to countries are many. The most significant one is that with the
Convention as a pathfinder and coordination vehicle, national public health policies, tailored
around national needs, can be advanced without the risk of being undone by transnational
phenomena (e.g. smuggling).
While framework conventions obligate States to cooperate in key areas, the process also
serves to forge important links between countries and other potential partners. Countries can
participate in the central framework while still deferring a decision on whether to participate
in protocols.
Framework Convention on Tobacco Control (FCTC) - A Primer
1. What is the FCTC?
The Framework Convention on Tobacco Control (FCTC) will be an international legal
instrument that will circumscribe the global spread of tobacco and tobacco products. This is
the first time that the WHO has activated Article 19 of its constitution, which allows the
Organization to develop and adopt such a Convention. In fact, the FCTC negotiations and
the adoption of the Convention should be seen as a process and a product in service of
public health.
This instrument will be developed by WHO’s 191 Member States so that their concerns are
adequately reflected throughout the process. In fact, the framework convention/protocol
approach will allow Member States to proceed with the process of crafting this piece of
international legislation in incremental stages:
• The Framework Convention will establish the legal parameters and structures of the
public health tool. If s a little like laying the foundation of a building.
•
The Protocols will be separate agreements that will make up the substantive part of the
agreement - building on the foundation.
2. When will it be completed?
Executive Board Resolution 103.R11 maps out a process for developing the WHO FCTC and
possible related protocols. This process, which will be considered by the World Health
Assembly in May 1999, foresees the adoption of the Framework Convention and possible
related protocols by the World Health Assembly no later than May 2003. Each negotiating
process is unique and has its own momentum. The FCTC can be completed earlier if WHO’s
Member States so decide. Much depends on political will and a sustained commitment to the
cause of public health. One option would be to negotiate one or more protocols
simultaneously with the Framework Convention.
In one case, for example, three Protocols were negotiated along with the main body of the
Framework Convention1.
3. How will the FCTC help international tobacco control?
I. The FCTC and related protocols will improve transnational tobacco control and
cooperation through the following avenues:
• The guiding principles of the Convention could encompass both national and
transnational measures making it clear that: tobacco is an important contributor to
inequity in health in all societies; as a result of the addictive nature and health damage
associated with tobacco use it must be considered as a harmful commodity; the public
has a right to be fully informed about the health consequences of using tobacco products;
and the health sector has a leading responsibility to combat the tobacco epidemic, but
success cannot be achieved without the full contribution of all sectors of society.
• Under the Convention, State Parties would take appropriate measures to fulfil, through
coordinated actions, the general objectives which they had jointly agreed to. In this
respect, the FCTC could include the following general objectives: protecting children
and adolescents from exposure to and use of tobacco products and their promotion;
preventing and treating tobacco dependence; promoting smoke-free environments;
promoting healthy tobacco-free economies, especially stopping smuggling; strengthening
women’s leadership role in tobacco control; enhancing the capacity of all Member States
in tobacco control and improving knowledge and exchange of information at national
and international levels; and protecting vulnerable communities, including indigenous
peoples.
•
The protocols could include specific obligations to address inter alia: prices, smuggling,
tax-free tobacco products, advertising/sponsorships, Internet advertising/trade, testing
methods, package design/labeling, information sharing, and agricultural diversification.
Unless national and transnational dimensions of tobacco control are addressed in tandem,
even the best comprehensive national control programs can be undone. The national and
global thrusts of the Convention, by the way, are interdependent.
II. The process of developing and adopting the FCTC and related protocols will also help to:
mobilize national and global technical and financial support for tobacco control; raise
awareness among several ministries likely to come into the loop of global tobacco
control, as well as various sectors of society directly concerned with the public health
aspects of tobacco; strengthen national legislation and action; and mobilize NGOs and
other members of civil society in support of tobacco control.
In the run-up to the adoption of the FCTC, the WHO and its Regional Offices will work with
NGO’s, media and civil society in countries to focus on tobacco in all its dimensions.
1 Reference is made to the “Convention on the prohibition and restrictions on the use ofcertain conventional
weapons which may be deemed to be excessively injurious or to have indiscriminate effects" (1980).
2
4. What is the difference between a treaty, a convention, a protocol and a
resolution?
• A treaty is an international legal agreement concluded between States in
written form, and governed by international law;
• A convention (and also a framework convention) is a different name for a
treaty;
• A protocol is also a form of treaty. It typically supplements, clarifies, amends
or qualifies an existing international agreement, for example, a framework
convention;
• A resolution is an expression of common interest of numerous states in
specific areas of international cooperation.
5. Which of the above is legally binding?
Treaties are legally binding. The framework convention usually entails more general or
limited obligations, while the protocols involve more specific legal obligations.
A resolution is non-binding and does not normally entail any substantive commitments of a
legal nature.
6. In this case wouldn’t a resolution suffice?
A resolution is not sufficient to deal effectively with the public health threats associated with
the tobacco trade, its marketing, and use. Over the past 25 years, the World Health Assembly
has adopted 16 resolutions on several aspects of tobacco control with varying degrees of
success. Some Member States have sharpened these resolutions domestically giving them
more focus and bite. This piece-meal approach, however, is too informal to be of any major
consequence, especially for tobacco control where the international dimension of the problem
has a direct bearing on how the issue is addressed domestically. However, resolutions
adopted in other international fora will undoubtedly support and act as a catalyst for the
FCTC process.
The Framework Convention is about tobacco control in the long run. The FCTC’s principal
advantage is that it will allow the WHO and its extended family - which includes individual
countries and individuals in countries - to reap the public health benefits resulting from the
control of tobacco and its spread through society. This is a legal instrument in service of
health.
7. What happened to the process started in 1996? Wasn’t there a work plan then?
In May 1996, the World Health Assembly adopted WHA Res. 49.17 calling upon the
Director-General of WHO “to initiate the development of a Framework Convention in
accordance with Article 19 of the WHO Constitution.” This was the first time the WHO was
activating its constitutional mandate (Article 19) to develop a convention. There were no
precedents for developing a detailed work plan. Between 1996-1998 some preparatory
technical work was undertaken, but no detailed work plan was agreed to. As part of that
work, a preliminary timetable was circulated during the 51st World Health Assembly in May
1998. The Tobacco Free Initiative took the relevant parts of that initial process into
consideration before developing this detailed work plan which reflects the political and
technical requirements for negotiating the FCTC.
3
8. The WHO already has a mandate to commence negotiations. Why are you seeking it
again?
WHA Res. 49.17 gives the Director-General a mandate to start work on developing a
Framework Convention in accordance with Article 19, but DOES NOT provide a mandate to
the Director-General to commence negotiations. The FCTC negotiation is a prerogative of
sovereign States, and requires the establishment of a formal negotiating body. Only the
World Health Assembly has the legal authority to launch the negotiating process. The
accelerated work plan and the draft resolution proposed by the Secretariat suggests that an
Intergovernmental Negotiating Committee be established by the Assembly to proceed with
formal negotiations. The role of the WHO Secretariat in this process is to provide technical
support and advice to Member States in the negotiation of the FCTC and related protocols.
9. What are the roles of the FCTC Working Group and the Intergovernmental
Negotiating Body?
Executive Board Resolution EB103.R11, which describes the FCTC Working Group and
Intergovernmental Negotiating Body, maps out an integrated process for developing the
FCTC and possible related protocols with the full participation of Member States. During the
May 1999 World Health Assembly, Member States will be asked to establish both a FCTC
Working Group and an Intergovernmental Negotiating Body. The mission of the proposed
FCTC Working Group, which will be open to all Member States, will be to prepare proposed
draft elements of the FCTC and to submit a report to the Fifty-Third World Health Assembly.
Formal negotiations will commence with the convening of the first meeting of the proposed
Intergovernmental Negotiating Body by the Director General, which is expected to occur in
May 2000. The Intergovernmental Negotiating Body, which will be open to all Member
States, will be charged with the responsibility of negotiating the text of the Convention and
possible related protocols.
10. Who is going to pay for the FCTC?
The budget for the FCTC will, initially, need to be financed through extra-budgetary funding.
These costs will include WHO technical support, support for intergovernmental technical and
negotiation meetings, and support for the establishment of FCTC national commissions to
provide support for the process within countries. In the medium to long-term regular budget
funds will be required to ensure sustained implementation.
In particular, developing countries will require financial and technical assistance to
participate in the process of formulating the FCTC. In this regard, the recent technical
consultation in Vancouver recommended that WHO establish a separate Trust Fund for this
purpose.
Resources will also be required during the implementation phase. Funds will be necessary to
help countries build capacity and participate in global and national tobacco control activities.
In this respect, provision should be made in the FCTC for the establishment of a Multilateral
Trust Fund, with contributions from governments, international agencies, and private sources.
11. Will resources from on-going tobacco control be diverted to the FCTC process?
New extra-budgetary funds will need to be committed to the FCTC process, but no
previously allocated funds for tobacco control will be diverted to support the FCTC process.
Support to the FCTC should be seen as an integral part of supporting national and global
tobacco control. In reality, the successful adoption of the FCTC will likely result in a marked
increase in financial resources for tobacco control both within countries and at the
4
international level. The FCTC, when adopted, will ensure that tobacco control is given a
higher political profile. The adoption of the FCTC represents a barometer of success or
failure in placing tobacco control front and centre on the global stage.
The environmental movement has been successful in having numerous multilateral binding
agreements adopted at the international level, and as part of some of these agreements, for
example the 1987 Montreal Protocol on Substances that Deplete the Ozone Layer, significant
financial resources have been made available to assist developing countries. Similarly, the
FCTC could facilitate global cooperative actions, including the flow of additional financial
resources.
12. What will happen to economies that depend on tobacco?
The widely held perception that tobacco control will lead to loss of revenues is really a
perception! In reality, the numbers are heavily in favor of moving away from tobacco
cultivation. Recent economic analyses, for example World Bank data to be published this
year, as well as the publication, (‘The Economics of Tobacco Control: Towards an optimal
policy mix ”, show that the social and health costs of tobacco far outweigh the direct
economic benefits that may be possible because of tobacco cultivation.
The tobacco industry relies on the argument that there are no real crop or other substitution
options. It is reasonable to assume that consumers who stop smoking will reallocate their
tobacco expenditure to other goods and services in the economy. Therefore, falling
employment in the tobacco industry will be offset by increases in employment in other
industries. However, in the short-term, for countries which rely heavily on tobacco exports
(i.e. the economy is a net exporter of tobacco), economic/ agricultural diversification will
likely entail employment losses.
The FCTC takes a long-term view of agricultural diversification. The framework-protocol
approach provides for an evolutionary approach to developing an international legal regime
for tobacco control, and thus all issues will not need to be addressed at the same time.
Further, the need for a multilateral fund to assist those countries which will bear the highest
adjustment cost needs to be established. The FCTC will probably be the first instrument
seeking global support for tobacco farmers.
Also, it is worth noting that the current 1.1 billion smokers in the world are predicted to rise
to 1.64 billion by 2025, mainly due to population increases in developing countries.
Therefore, tobacco growing countries are extremely unlikely to suffer economically from any
tobacco control measures such as the FCTC.
13. Which ministries are expected to be involved in the negotiations?
In addition to the leading role of the Ministries of Health, Ministries of Foreign Affairs
typically take a lead role in the negotiation of conventions/treaties. Ministries of Finance,
Environment, Labour, Justice, Foreign Trade, Education and Agriculture will also be
expected to come into the ambit of the negotiations at some point.
14. Do internationally binding conventions/treaties lead to action and tangible results?
Adopting an international agreement can make a significant difference. For example:
5
•
Production and consumption of substances that deplete the stratospheric ozone layer
have declined dramatically over the last decade, as a result of the Montreal Ozone
Protocol.
•
The General Agreement on Tariffs and Trade has brought down trade barriers and
promoted the expansion of international trade.
•
Arms control agreements have limited nuclear weapons proliferation and have led to a
substantial reduction in the arsenals of the nuclear powers.
Can international agreements affect the behaviour of States? In some cases, international
agreements establish meaningful enforcement mechanisms, such as the World Trade
Organization’s dispute settlement system. But even in the absence of such mechanisms, an
international agreement can:
•
establish review mechanisms that focus pressure on States by holding them up to public
scrutiny;
•
articulate legal rules that may be enforceable in domestic courts;
•
provide supporters within national governments with additional leverage to pursue the
treaty’s goals.
Thus, while treaties rarely cause a state to immediately reverse its behaviour, they can
produce significant shifts in behaviour, both because they change a State’s calculation of
costs and benefits, and because most states feel that they ought to comply with their
promises.
15. Why should the FCTC be developed and negotiated under the auspices of the World
Health Organization, rather than, for example, under the umbrella of the United
Nations?
The World Health Organization is the only international multilateral organization that brings
together the technical and public health expertise necessary to serve as a platform for the
negotiation and effective implementation of the Framework Convention on Tobacco Control.
Although the United Nations also has the legal authority to sponsor the creation of
international instruments on tobacco control, the UN has neither the specialized
technical expertise nor, perhaps, the time to engage in negotiating complex standards on
tobacco control, particularly if extensive negotiation of the Convention is required.
Complex technical standards on tobacco control should be established and monitored by
WHO, the primary specialized agency in public health. In WHA 49.17 Member States
recognized the unique capacity of WHO to serve as a platform for the adoption of the FCTC
by calling upon the Organization to initiate the development of the Convention.
However, in so far as the ultimate goal of global tobacco control may require the regulation
of areas falling within the mandate of other United Nations’ Bodies establishment of a joint
negotiating mechanism, especially with regard to possible specialized protocols, could be
considered as an option.
6
16. What linkages will the work on the FCTC have with other regional /international
agreements, which could have added value for the FCTC?
Under the WHO/UNICEF project, “Building alliances and taking action to create a
generation of tobacco-free children and youth, supported by the United Nations Foundation,
a review of the Convention on the Rights of the Child with respect to tobacco control, is
currently being conducted. Also, with respect to TFI’s work on strengthening the role of
women in global tobacco control, possible links between the FCTC and the United Nation’s
Convention on the Elimination of all Forms of Discrimination Against Women (CEDAW),
will be considered. Links between the FCTC and other international treaties addressing
issues such as smuggling will also be examined. Furthermore, all efforts will be made to
build on proposed and existing regional tobacco control agreements.
7
world ino iobacco Day ZUUU
Page 1 of3
Pn
Tobacco Free Initiative
□ Upcoming Events
□ Contacts
Update
□ FCTC Second Working
Group -March 2000
i> Director General's
opening address
-English
-Frangais
□ Second Session of the
United Nations Ad Hoc
Interagency Task Force
on Tobacco
-Final Report
□ World No-Tobacco
Day 2000
Framework Convention
on Tobacco Control
(FCTC)
□ FCTC Page
□ FCTC Working group
□ New Delhi Conference
- Back g roii nd pa pe rs
available
C3 Oslo Conference on
regulating tobacco
products
> World Health Assembly
Paves Way for FCTC
> Globalization of Tobacco
Perspectives, Trends &.
Impacts on 1 luman
Welfare (word)
Economics of Tobacco
Control
World Bank Report
□ Curbing (he Epidemic:
Governments and the
Economics of Tobacco
Control
National Capacity Legislations
□ African Inter
parliamentarian meeting
in Lome
□ Second Call for Legally
Qualified Individuals
avOCLO
VMACCO O*» <0 • » M«ff
World No-Tobacco Day 2000. 31 May.
World NQ-Tobacco Day 2000„p(>sters
PDF format
Print Ready Files
jTheme - Entertainment and Tobacco Promotion- Countering the Deception
Slogan - Tobacco Kills - Don't Be Duped
Objective - To pave the way for national and global policy action banning the
iadvertising and promotion of tobacco.
Rationale
iOne of the primary objectives of the tobacco industry is to frame tobacco use as an
’individual and behavioural decision. The problem with this casting is that it leaves
the tobacco industry's activities and practices completely out of the equation. It
assumes that people make decisions in a state of vacuum, completely uninfluenced
by their environment including industry advertising and marketing.
Tobacco advertising and use in the entertainment and sports industry projects images
of smokers as fun loving and glamorous and, most insidiously, healthy. Attractive
images and people suggest that smoking is a powerful tool for enhancing self-image.
The illusion helps the tobacco industry sell a product that kills.
"The tobacco companies spend $6 billion a year enticing youth to
smoke. ... They make you believe that ifyou smoke, you're going to be
sexy, attractive, successful, accepted by your peers, rocking, and
macho, cool and sassy. They project this image in every media - from
day—time movies to night-time movies, magazines and even cartoon
characters, " says former "Winston" man turned tobacco control
activist Allan Landers.
There is evidence to show that people's decision to smoke is enhanced by advertising
and promotion of tobacco especially in the entertainment, sports and music industry.
The Tobacco Industry understands this well and actively markets tobacco in many
parts of the world through a strategic and insidious mix of pricing, placement and
promotion. Sponsorship and product placement in films and sports are key strategies
used by the Tobacco industry to circumvent advertising restrictions, where they have
been enacted. Tobacco control work cannot and need not hope to match the
http://www.who.int/toh/media/wntd2000/wntd2000.htm
5/15/00
World No Tobacco Day 2000
□ Tobacco Legislation
Compendium
□ A Global Agenda for
1 obacco Control
research (word)
Media and Information
□ Press Releases
□ World Community joins
WHO in holding up
mirrors to big tobacco
□ World No-Tobacco
Day 2000
□ WHO Don’t Be Duped
Campaign
□ World No-Tobacco Day
1999
-World Tobacco Control
Medal Winners 1999
Page 2 of 3
■auvci uaiHg <inu piuiiiuuuimi wuijv ui me luuaixu inuuauy. vv iui science, juautc,
public health and economics on its side, tobacco control work can stay ahead on the
infonnation curve and seize the public health initiative on this issue.
Standing up to the culture vultures
World No Tobacco Day 2000 (WNTD 2000) aims to raise awareness of and counter
these global marketing practices of the tobacco industry which lure customers,
(especially young people, through sponsorship, advertising and glamourisation of
(tobacco in films, music, art and sports.
lit will serve as a catalyst to reframe the tobacco debate by:
• disseminating information about the untruthful, deceptive and manipulative
marketing practices of the tobacco industry, as revealed in their own "secret"
documents;
• sharing global and national tobacco control experience in countering this
deception; and
• creating a powerful international alliance of artists, sports and media people
endorsing tobacco control issues.
Director General on
Tobacco
□ Speeches
- International Conference
on Global Tobacco Control i
Law (Word document)
□ Selected quotes
□ Gro Harlem Brundtland
United Nations and
Tobacco
□ Ad Hoc Interagency
Task Force on Tobacco
Control
It will pave the way for the larger policy debate on the pressing need for globallybinding advertising and promotional bans on tobacco.
May 31 - On World No Tobacco Day
Regions and countries will organize their own events. It is hoped that each Region
will engage relevant entertainment personalities. Thailand is the venue for the global
WNTD event on May 31st, 2000. A separate organising committee has been set up
under the guidance of Dr. Varabhom Bhumiswadi, Director, Institute of Tobacco
Consumption Control, Department of Medical Sciences, Ministry of Public Health.
TFI and SEARO are involved with MOH Thailand in planning local events in
Bangkok. For more information on events and actions on WNTD, please contact]
iMartha Osei, Reagional Advisor on Health, SEARO.
—■
Treatment for Tobacco
Dependence
An international Quit and Win contest is being organised to encourage people to quit
smoking. For further details on this, please contact Dr. Peter Anderson, Action plan
for a Tobacco Free Europe
□ Statement on Treatment
for Tobacco Dependence
x Franca is - Espa no I
Events are being planned in Geneva, New York and other cities around the world watch this space and tell us what you are planning in your city!!
Women and Tobacco
□ Kobe Declaration
□ Kobe Conference
□ Kobe: Dr Brundtland's
address
□ Kobe Declaration calls
for a hah to the tobacco
menace among women
and children
The ’’Insider"
Major International Opportunity for Entertainment Focus on Tobacco
A Walt Disney film called "The Insider" starring Al Pacino and Christopher Plummer
will be released in the US on November 5th, 1999. It is the story of Dr. Jeffrey
Wigand, former vice-president, (R&D), Brown and Williamson. Dr.Wigand blew the
whistle on the tobacco industry's nicotine manipulation. The film recounts his
struggle and the tobacco industry's tactics to silence him and his work. Dr. Wigand
launched TFI's "Tobacco Kills - Don't be Duped" global media and NGO campaign
and he is availabe for appearances. You may contact Dr. Wigand directly at
Youth and Tobacco
□ Youth Page
Q International
Consultation on Youth
and Tobacco
□ Opening Address by
Derek Yach
Products
A series of products are being released from November 1999. All products will be
branded with the "Bob" image.
1) Overview and Rationale for the focus on entertainment and tobacco
http://www.who.int/toh/media/wntd2000/wntd2000.htm
5/15/00
..
World No Tobacco Day 2000
Religion and Tobacco
□ Reunion sur la religion
ci le (abac (word)
□ Meeting on tobacco
and religion (word)
Passive Smoking
□ International
Consultation on
Environmental Tobacco
Smoke (ETS) and Child
Health
WHO-TFI Governance
□ World Health
Assembly, 52nd Session
WHA Documents
> Arabic
Chinese
z English
EspanoI
z Franca is > Russian
□ Executive Board. 103rd
Session TFI: To wards
Stronger Global Action
World Health Report
1999
□ Combating the epidemic
(pdf)
□ WHO Publications,
Technical Reports.
Journal Articles.
Resolutions, etc.
Tobacco on the Web
x Links to tobaccorelated sites
Page 3 of3
2) Menu of four posters
Rights have been secured from the Department of Health Services, California to use
the "Bob" posters. Countries will be offered several options." The redesigned posters
to say "Bob, I've got cancer." Available on this website. CD Rom's available from
WHO Regional offices.
3) Video News Release (VNR)
—
;An advocacy VNR about TFI's work with the Insider with quotes from Dr. Derek
'Yach, Dr. Wigand, Al Pacino, Michael Mann , the producer of the film can be
obtained from Sandra Khadouri, Producer, Phoenix Television, London,
4) Public Service Announcements (PSA’s,) - TFI has negotiated and obtained
rights from CDC for two PSA's featuring super model Christy Turlington and pop
group Boyz 11 Men. Both have serious anti-tobacco, anti-deception messages. PSA'a
ready and available with regional offices.
Other proposed activities /events
TFI invites countries, NGO's, individuals and all interested parties to consider the
following list of events they could organise. Among these:
• Convene a meeting of television and film writers and directors to discuss the
global impact of smoking in films
• Publicise the tobacco toll on the entertainment industry and sports figures.
• Sponsor tobacco-free concerts with partners. Invite entertainers to include
tobacco-free settings for their concerts/venues/cafes.
• Develop WHO-Score Card/Rating System of PR companies and advertising
agencies that don't or do promote tobacco.
• Asa corollary to the former, initiate "centimetres against tobacco" for people
worldwide to buy space, air and television time for public sponsored tobacco
control advertisements.
• Promote "Spot a Collusion" contest worldwide to trace sponsored writing by
journalists paid by the tobacco industry.
• Regional promotional events with Wigand around film launch
Copyright T 199S .
All rights reserved.
UpdatediThu Apr 13
13:00:51 2000
http://www.who.int/toh/media/wntd2000/wntd2000.htm
5/15/00
ci-
Message from the director-general
World Health Organization for
World no-tobacco day 1996
"Play it tobacco-free!"
The lives and accomplishments of sports heroes, leading actors, musicians and other artists are
highly visible and attract widespread interest all around the world. Young people in particular
look to sports stars and art performers as role models. It is fitting therefore that World No
Tobacco Day 1996 should be dedicated to the theme "Sport and the arts without tobacco".
Athletes and artists can lead the way in promoting healthy lifestyles where tobacco use is no
longer the social norm.
Every year, World No-Tobacco Day is a special occasion for the World Health Organization and
people from all its Member States to call attention to the harm that results from tobacco use. It is
also a day when governments, communities, groups and individuals together explore the ways
through which they can stem the tobacco epidemic, and especially prevent young people from
becoming addicted to this harmful substance. We applaud those individuals who have already
given up tobacco use, and encourage those who still use tobacco to make a special
effort to
finally break free from this dependence.
World No-Tobacco Day 1996 is co-sponsored by the United Nations Educational, Scientific and
Cultural Organization (UNESCO) and the International Olympic Committee (IOC). These
organizations have welcomed the initiative of combining sport and the arts to promote, jointly
with WHO, the prevention of tobacco use. They too have fully realized the importance of
athletes and artists as role models who can convince the public in general and young people in
particular that a healthy lifestyle should be "smoke-free".
Communities and societies express themselves through their arts and culture. Promoting good
health and a tobacco-free lifestyle in conjunction with cultural and artistic events will contribute
not only to improving people's health but also to giving full expression to the creativity and
vitality of different groups and cultures.
We also want to promote "sport for all" as the right for all human beings to participate in sport
and physical activities for recreation and to improve their health and well being. Regular
physical activity is vital for good health: it provides protection from a wide variety of physical
and mental ailments. Physical fitness and good health, however, can be ruined by tobacco use. It
is estimated that about half of the adolescents who start smoking cigarettes and continue
throughout their lives will eventually die from tobacco-related diseases. Not only smoking but all
forms of tobacco consumption are extremely hazardous. Unfortunately, the tobacco industry has
geared its efforts towards developing positive images for its products through extensive
sponsorship of sports and cultural personalities, organizations and events. In many countries,
sport and the arts rely heavily on sponsorship from commercial enterprises, and tobacco
companies are among the main sponsors. In many cases, sports and cultural events, which should
celebrate good health, physical prowess, intellectual freedom and cultural independence, are
cynically used as an opportunity to promote addictive and hazardous products among the young.
In contrast, tobacco-free sports and cultural events are ideal venues to promote good health and
healthy lifestyles. Alliances must be forged between the public, the health sector and all those
who are active and interested in sports and the arts to sponsor sports and cultural organizations so
that these no longer need to depend on tobacco sponsorship.
This has been done in many places around the world as illustrated by the examples attached in
this Media Kit. Health organizations can sponsor sporting and cultural activities, and in so doing
create major opportunities to convey their health promotion messages in novel and effective
ways. Such sponsorship, however, requires resources. Some governments have generated new
revenue for this purpose by increasing taxes on tobacco products, a measure which has also
helped to decrease tobacco consumption.
The sponsorship of sports and the arts by tobacco companies is now widely recognized as
ethically unacceptable. More and more people and communities are giving precedence to health
and being able to live in a tobacco-free environment. With all the people and sectors concerned,
WHO will work to promote tobacco-free events, which celebrate good health together with
excellence in sports and the arts - a winning combination for all!
Dr Hiroshi Nakajima
Director-General
World No Tobacco Day - 31 May
Theme for 2002
Tobacco Free Sports--Play it clean
Global deception
What must you do to market a product that kills half of its regular users? What
enticements must you resort to in order to addict those regular users early, sometimes as early
as nine years old? How do you package death as life, disease as health and deadly addiction
as the taste of freedom and a celebration of life?
Look no further than your nearest playground or that shirt on your favourite
athlete’s back or the shoe, or the bag, or the jacket. Look no further than tobacco companies’
own documents that tell you how they promote tobacco in the playground to unsuspecting
children. Compare these documents to the public relations spin that the tobacco companies
regularly put out—their words don’t fit their actions.
In this attempted diversion is the deception. In the deception is disease and in one
out of two cases, sure death. Tobacco kills. To replace those who die, the tobacco industry
needs to recruit smokers around the world. Nothing is taboo - not even a forlorn sports
ground where children gather to play.
The World Health Organization (WHO) says tobacco is a communicated disease
communicated through advertising and sponsorship. Perhaps the most pernicious form of that
marketing pitch is to be found in stadia and sports arenas worldwide.
Tobacco companies pump millions of dollars every year into sponsoring sports
events worldwide. In the United States alone, according to the Federal Trade Commission,
the major domestic cigarette companies reported spending $113.6 million on sports and
sporting events in 1999. In countries where direct tobacco advertising is banned by law,
sponsorship of sports amounts to a cynical manipulation of national laws. Despite a federal
ban on tobacco advertising on television, it is estimated that tobacco companies achieve the
equivalent of more than $150 million in television advertising every year in the U.S. through
their sponsorship of motor sports events.
Tobacco companies claim they are sponsoring sports out of a sense of
philanthropic duty. Their internal documents, however, tell another story.
An internal R.J. Reynolds (the company is now owned by Japan Tobacco) memo
from 1989 has this to say: "We're in the cigarette business. We're not in the sports business.
We use sports as an avenue for advertising our products. We can go into an area when we're
marketing an event, measure sales during an event and measure sales after the event, and see
an increase in sales."
That is no idle boast. When an Indian associate of the British American Tobacco
group sponsored the Indian World Cup Cricket in 1996, a survey showed that smoking
among Indian teenagers increased five-fold. There was also marked increase in false
perceptions about athletic excellence and smoking.
The deception is for the public. The dollars are for the companies. And the death
and disease burden is for countries to cope with. Tobacco companies know exactly how many
smokers they can get for every dollar spent on advertising in the sports arena. ’’We're not
handing out money for nothing. We have gone into this very thoroughly and the
entire...publicity is built around motor racing seen as a fast, exciting and trendy sport for the
young and, if you like, the young at heart. That's who we are aiming at in the local market
and early indications are that we are on target," said Gordon Watson, BAT official quoted in
the South China Morning Post in 1984.
The company is on target, but so are the death rates. Some twenty years after that
early addiction set in, new studies show that one-third of Chinese men currently under 29
years of age will die prematurely due to a tobacco-related disease. Of the 8.4 million tobacco
deaths that will occur by 2020, seven out of ten will occur in the developing countries.
Global appeal
Sport is a celebration of life. From the impromptu game in the park to school
teams and local leagues to national championships, world cups and the Olympics—sports
inspire healthy living, healthy competition and fun.
Tobacco products, on the other hand, do not celebrate life—they cause disease
and death. Tobacco kills more than four million people every year, and is estimated to kill 8.4
million people every year by 2020.
For the professional athlete, tobacco use lowers performance level and can end a
career. For the casual sportsperson or participant in a sport for recreational purposes, tobacco
use reduces their ability to play the game. For the spectator of sports events, tobacco use and
exposure to second-hand smoke contributes to the development of disease and reduces their
enjoyment of the game. For sports teams and facilities, tobacco advertising and sponsorship
run counter to the ideals of health and fair play embodied in sports. For the companies who
co-sponsor sports events along with tobacco companies, the reputation of the "hazard
merchants" becomes indelibly associated with their products. In short, tobacco and sports do
not mix.
Many athletes, sports fans and spectators are young people. Recent data suggest
that one-third of young smokers start before the age of ten. Youth consumption of tobacco is
up in many parts of the world. Most people who start so young become addicted to nicotine
very early in life. Unable to quit they become heavy users and continue using tobacco
throughout their lives. Millions of these young people will eventually die due to tobaccorelated causes.
Tobacco companies claim that they do not target youth, but in practice they
ensure that sponsorship and advertising flourish at events attended by and are attractive to
youth. Team jerseys and caps, tote bags and T-shirts, fields and stadia, cars and sports
equipment bearing tobacco brand logos create a positive association between tobacco and the
strength, speed, grace, success, fun and excitement of sports.
Global response
Sports federations and sportspeople around the world know tobacco is
incompatible with their values and their health. Athletes take pride in their strength, skills,
and dedication and in their ability to act as positive role models for all of society. They want
to put an end to tobacco’s manipulation of sports.
Countries want to reclaim their right to protect public health. WHO’s 191 Member
States are negotiating a global public health treaty to bring down tobacco-related deaths. The
Framework Convention on Tobacco Control FCTC) will mesh science and economics with
legislation and regulation and in some cases, litigation. It will seek global and national
solutions for problems such as global tobacco advertising or smuggling—issues that cut
across national boundaries, cultures, age groups and socio-economic strata. In fact, the FCTC
is a call for international scrutiny and responsibility that normally accompanies a freely
available consumer product in the international marketplace.
Under pressure by this global call for an end to the deception and the resulting
death, tobacco companies are unleashing yet another attempt to derail meaningful regulation
of their corporate activity. In this round of recycled arguments, companies such as British
American Tobacco, Philip Morris and Japan Tobacco now promise to enforce "International
Tobacco Marketing Standards". They propose to enforce these standards voluntarily and to
target advertising only at adult smokers.
WHO says no country has succeeded in designing regulations—especially voluntary
ones—that eliminate children’s exposure to tobacco advertising while allowing advertising
aimed only at adults who use tobacco. Self-regulation invariably fails because it was never
meant to succeed - tobacco companies know this and now so does the rest of the world.
Tobacco Free Sports—Play it Clean
In response to the global appeal for action, WHO and its partners are launching a
campaign to clean sports of all forms of tobacco—tobacco consumption, and exposure to
second-hand smoke, tobacco advertising,The United States Centers for Disease Control and
Prevention (CDC), International Olympic Committee (IOC),Federation Internationale de
Football Association (FIFA), Federation Internationale De L’Automobile Association (FIA),
Olympic Aid and other regional and local sports organizations will join WHO in this
campaign for Tobacco Free Sports. Tobacco free events will be organized all over the world,
including the 2002 Salt Lake City Winter Olympic Games in the U.S. and the 2002 FIFA
World Cup in the Republic of Korea and Japan.
Athletes, sports organizations, national and local sports authorities, school and
university sports teams, sports media and everyone interested in physical activity are invited
to join this campaign for Tobacco Free Sports. WHO urges people everywhere to take back
their right to health and healthy living and to protect future generations from the preventable
death and disease caused by tobacco?
ptx -3
Evolving educational strategies for Tobacco control among students
Venue: International Nursing Services Association (INSA)
2/1, Benson Road, Benson Town, Bangalore- 560 046
Phone: 3536699/3536633
Date:
Friday, 18th October, 2002
Time: 9.00 am to 1.00 pm
Objectives
At the end of the discussion the participants will be able to
□ Learn about the issues involved in tobacco control
j
Understand the strategies used elsewhere
□ Discuss the strategies for Bangalore and Karnataka
SI No
1.
Time
2.
10.00 10.30 am
3.
10.30- 11.00 am
4.
11.15
5.
11.30 am
noon
6.
12.00 noon 1.00- pm
7.
9.30. -10. 00 am
11.30 am
12.00
Topic
History of tobacco
use. Global
Scenario and
Indian, Karnataka
scenario
Health Implications
Methodology
Lecture
Audio Visual aids,
interactive
Interactive and Audio
Economic
Visual aids
Implication
11.00 to 11. 15.00 am Tea break
Environmental and Audio Visual aids
and interactive
Social Implication
Strategies used
elsewhere, TFI,
FCTC, NOTE.
SHAN________
Strategies for
Bangalore and
Karnataka follow
up action plan
1.00 pm
Resource person
S.J.Chander
Dr. Anant & Dr.
Rajkumar
S.J.Chander
Naveen Thomas
S.J.Chander
Dr. Rajkumar
Lecture and Audio
Visual aids
Dr. Rajkumar
S.J.Chander
Dr. Anant Bhan
Group discussion
Presentation.
S.J.Chander
Dr. Rajkumar
Dr. Anant Bhan
Conclusion and lunch
,r
ICING THE ENVIRONMENT TO H
GROW UP TOBACCO-FREE
f'-..
=
k W'S1 ■'
'■
COMPREHENSIVE POLICIES AND PROGRAMMES ARE NECESSARY
Children do not simply "choose" to smoke. They are greatly influenced by their
environment, which is greatly influenced by public policies. Children arc much more
likely to smoke if they are surrounded by attractive tobacco advertising and promotion; n
their favourite sport is sponsored by a tobacco company; if their film idols smoke in the
movies: if they see people smoking all around them; and if tobacco products arc cheap
and readily available to them.
Educational programmes serve a purpose, particularly in countries where the harms of
tobacco use are not widely known. However, without sound public policies, the billions
of dollars tobacco companies spend promoting their products and creating a "pro
tobacco" environment for children can overwhelm the healthy messages children rcccixc
from parents and in the schools. Strong public policies help level the playing field and
give children a real chance to grow up tobacco-free.
W hich Youth-Oriented Policies Work?
Policy experts agree that a combination of the policies described below should
significantly reduce tobacco use by youth, provided they are sustained over time, and
strictly enforced, and adequately funded. For real progress to be made, it is also
important that all of the recommended policies be implemented. Although benefits w ill
be realized through the implementation of even one of these policies, a comprchensix e
approach works best. Tobacco companies denied one approach to marketing or selling
tobacco products to children will redouble efforts using any other methods that arc not
prohibited.
All of these policies are included within WHO's Ten-Point Programme for Successful
Tobacco Control. The following points, derived from World Health Assembly
resolutions, along with recommendations from other international and intergovernmental
bodies lists some key elements that should be included in comprehensix e national
tobacco control programmes.
1. Protection for children from becoming addicted to tobacco.
Use of fiscal policies to discourage the use of tobacco, such as tobacco
taxes that increase faster than the growth in prices and income.
3. Use of a portion of the money raised from tobacco taxes to finance other
tobacco control and health promotion measures.
4. Health promotion, health education and smoking cessation programmes.
Health workers and institutions set an example by being smoke-free.
5. Protection from involuntary exposure to environmental tobacco smoke
(ETS).
6. Elimination of socio-economic, behavioural and other incentives which
maintain and promote use of tobacco.
7. Elimination of direct and indirect tobacco advertising, promotion and
sponsorship.
8. Controls on tobacco products, including prominent health warnings on
tobacco products and any remaining advertisements; limits on and
mandatory reporting of toxic constituents in tobacco products and
tobacco smoke.
9. Promotion of economic alternatives to tobacco growing and
manufacturing.
10. Effective management, monitoring and evaluation of tobacco issues.
Higher tobacco taxation
Studies consistently show that children are more sensitive to price increases than adults.
In the United States, for example, youth are about three times more likely than adults to
quit smoking, or not to start smoking, in response to a tobacco price increase. Increasing
the price puts a higher barrier between youths and easy access. Thus, tobacco tax
increases are good health policy and good fiscal policy. Cheap cigarettes are not a social
benefit, because they encourage more smoking, causing higher health care costs and more
death and disease. One other way to make cheap cigarettes less accessible to young
people would be to legislate against single sales of cigarettes as well as half-size cigarette
packages, known in some countries as ’’kiddie packs".
In many countries, governments earn substantial tax revenue from illegal sales of tobacco
products to minors, but often are putting only a small percentage of it back into
prevention programmes for young people. It is uniquely appropriate that a portion of
funds raised by tobacco taxes be used to fund programs to protect children and reduce
tobacco use. This funding approach has been used in Australia, the United States. Canada
and other countries, and has proven to be effective and politically popular.
Multisectoral collaboration
The Jakarta Declaration On Leading Promotion into the 21st Century (Jakarta. July 199")
identifies international trade in tobacco as having a major negative impact on public
health, and consequently the health of children. It calls for the creation of new
partnerships for health, between governmental and nongovernmental organizations,
betw een public and private sectors at all levels of governance in society and for the
Ibrmation of a global health promotion alliance. Such concerted intersectoral and
transnational efforts are urgently required to counteract the efforts of the multinational
tobacco companies.
Marketing restrictions
Advertising affects young people's perceptions of the pervasiveness, image, and functions
of smoking. Studies have shown that in some countries, tobacco advertising is tw ice as
influential as peer pressure in encouraging children to smoke. Children are often more
likely to buy the most heavily advertised brands of cigarettes. Because tobacco
advertising is inherently misleading, public policies should prohibit all tobacco
advertising and promotions, including free samples and other giveaways, sale of non
tobacco products that carry a tobacco brand name, point of sale advertising and tobacco
company sponsorship of sporting and cultural events. Those countries which have
adopted bans on tobacco advertising as part of a comprehensive tobacco control
programme have seen significant declines in tobacco consumption.
Prohibition of sales to minors
In many countries, tobacco products are routinely sold to children, while selling other
addictive, lethal drugs to children is not tolerated. A minimum age of 18 or older should
be established for tobacco sales. All tobacco retailers should be licensed and their license
should be contingent on obeying the law. A graduated schedule of civil penalties ranging
from a warning to license revocation should be established. Enforcement is critically
important! If these laws are not enforced, they will not be obeyed. Enforcement funds
may be raised from licensing fees and penalties, so these measures can be selfsupporting. To eliminate possibilities of unsupervised sales of tobacco products, vending
machine sales should be prohibited.
In recent years, tobacco control programmes in a number of countries have
attempted to limit the possibility that cigarettes will be sold to minors. However,
even where these programmes are effective in limiting actual sales, the majority
(of young people still think that obtaining cigarettes is easy. Studies found that
many regular adolescent smokers do not buy their own cigarettes. Older siblings
and acquaintances are clearly prepared to purchase for underage minors.
Therefore, while strategies to reduce the availability of tobacco products to
young people are important, they will be of only limited value unless
accompanied by comprehensive tobacco control programmes.
Countermarketing and education programmes
Many governments have established successful programmes using the mass media to
provide strong messages designed to counter the image promoted by cigarette companies
of tobacco use as sexy, glamorous and normal. Equally important are school-based and
community-based programmes to teach children about the dangers of tobacco use and to
leach them the skills they need to resist tobacco marketing efforts and peer pressure.
Research shows that coordinated mass media programmes and education programmes
produce much belter results than either approach by itself.
Protection from environmental tobacco smoke
It is important that smoking be legally prohibited in public places, especially where
children may be present. First, environmental tobacco smoke has been established
beyond question to be harmful to all people, and especially to children. Second, if public
places become smoke-free, then young people will have far fewer places to light up. and
this could go a long way in reducing smoking. Finally, children who grow up seeing
smoking permitted all around them will wrongly conclude that smoking must not be ver\
harmful, and that it is socially acceptable to smoke. Incidently, tobacco companies work
very hard to make smoking appear socially acceptable. The 1988 mission statement ol
one tobacco company in Canada included the following intention: "support to continued
social acceptability of smoking through industry and/or corporate actions."
HOW TO PROMOTE TOBACCO CONTROL POLICIES
Although tobacco is much more than a youth issue, emphasising the harms to young
people may be useful in generating support for tobacco control among politicians and the
general public. Even smokers are more likely to support tobacco control legislation if
they believe it will help prevent children from starting to smoke. The rationale that
children may not be in a position to make informed and rational decisions about whether
or not to become tobacco users can also help further policies which will help protect
children from the pressures to use tobacco.
Policies to protect children from tobacco can be passed in many forms and at many
different levels of government (e.g., local, provincial, national and international ). Policies
may be passed most easily as regulations in some places and as legislation in others. In
most countries, however, nongovernmental organizations (NGOs) play a critical role in
promoting passage of tobacco prevention laws.
Successful campaigns generally follow three stages:
Advance research and planning
Il is important to gather as much information as possible at the outset about the issue,
define feasible objectives and strategies, and determine who are likely allies and
opponents, what the public thinks, whether a strong coalition can be formed, and how a
campaign can be funded. Research and planning will be necessary throughout, but it is
never more important than at the beginning.
Launching the campaign
If (he advance research and planning suggests that a full-scale campaign is warranted, the
next step is to bring the issue into focus for the media and politicians and gel it onto the
public agenda. Events such as release of a study supporting new policies, a press
conference, introduction of legislation, expressions of support by leading politicians, etc .
can be planned to keep public attention on the issue. Positive media exposure is often the
kev to success.
Lohhx ing for passage
If the proposal is a good one, opposition from the tobacco industry will be fierce and the
campaign will be hard-fought. There will be many challenges; clever tactics by the
opposition will have to be anticipated and defeated. A successful campaign must be
tireless, strategic and aggressive. Help from experienced lobbyists who know the
politicians involved can be extremely helpful. International support for the measures can
also prove very useful?
Il will be important to broaden the base of support for the proposal at every stage, and to
maintain a positive, reasonable approach. Politicians and the media alike will shun
organizations and individuals they believe are too extreme.
Of course, many campaigns do not succeed at first, and so the issue must be fought again
and again until a proposal passes. Even after the proposal becomes law. the job is not
done. The gam must be protected from future attacks. For example, will the law be
strictly enforced? Is adequate funding appropriated? After every victory or defeat, it is
important to thank allies, learn from successes and failures, and regroup for the next
campaign.
Beyond prevention helping teens quit smoking
There is often a lack of smoking cessation resources designed for young people
As countries strive towards tobacco-free societies, prevention of smoking among youth IS
of key importance. However, around the world, high rates of smoking among teens
provides a strong argument for effective youth-oriented smoking cessation programmes
A\ ailable information suggests that physical and psychological dependence on smoking
can develop quickly in young people. By the time teens have been smoking on a dail\
basis for a number of years, the smoking habit and addiction levels may w ell ha\c
become entrenched, and they are faced with the same difficulties in quitting as adult
smokers. Although intentions to quit and quit attempts are common among teenagers,
only small numbers of teenagers actually quit. One of the problems may well be the lack
of smoking cessation resources tailored to young people.
Recent studies have found that students would welcome smoking cessation assistance if
provided in acceptable'ways. It appears that some groups of students prefer more
independent quitting strategies, such as self-help programmes or "quit and win" style
incentives. However, this will vary among populations, and will need to be determined
before interventions are planned.
Tobacco addiction and kids
The younger people start smoking cigarettes, the more likely they are to become sirong/\
addicted to nicotine.
Tobacco products contain substantial amounts of nicotine, which is absorbed easily from
tobacco smoke in the lungs and from smokeless tobacco in the mouth or nose. Nicotine
has been clearly recognized as a drug of addiction, and tobacco dependence has been
classified as a mental and behavioural disorder according to the WHO International
Classification of Diseases, ICD-10 (Classification Fl7.2). Experts in the field of
substance abuse consider tobacco dependency to be as strong or stronger than
dependence on such substances as heroin or cocaine. Moreover, because the typical
tobacco user receives daily and repeated doses of nicotine, addiction is more common
among all tobacco users than among other drug users. In many countries, about 90% of
smokers smoke every day, and approximately that proportion or perhaps even more are
dependent on tobacco. Among addictive behaviours, cigarette smoking is the one most
likely to take hold during adolescence. A study found that 42% of young people who
smoke as few as three cigarettes go on to become regular smokers. What often starts out
as an act of independence may rapidly become an addictive dependence on tobacco.
Studies by health scientists in the United States have found that about three-fourths of
under-age smokers consider themselves addicted, while a majority of adolescent smokers
in Australia had tried to quit and found it very difficult. About two-thirds of adolescent
smokers in another USA study indicated that they wanted to quit smoking, and 70% said
that they would not have started if they could choose again. These responses are
remarkably similar to the conclusions of studies conducted years earlier for a Canadian
tobacco company:
"However intriguing smoking was at 11, 12 or 13, by the age of 16 or 17 many
regretted their use of cigarettes for health reasons, and because they feel unable to stop
smoking when they want to. "
Danger!
PR in the playground
Tobacco industry initiatives on Youth smoking
"We believe in our right to provide adult smokers with brand choice and information,
alongside our responsibility to ensure that our marketing does not undermine efforts to
prevent children from smoking. [Martin Broughton. Chairman of BAT. 20()0][l]
■‘In all my years at Philip Morris. Tve never heard anyone talk about marketing to youth."
[Geoffrey Bible. CEO of Philip Moms. 1998][2]
‘If younger adults turn away from smoking, the industry will decline, just as a population
which does
not give birth will eventually dwindle.'
[Diane Burrows, RJ Reynolds, 1984][3]
. We refined the objective of a juvenile initiative program as follows: “Maintain
and proactively protect our ability to advertise, promote and market our products via a
juvenile initiative*”.
* Juvenile Initiative = a series of programs and events to discourage juvenile smoking
because smoking is an adult decision.”
[Cathy Leiber, Philip Morris International, 1995][4]
“As we discussed, the ultimate means for determining the success of this program will
be: 1) A reduction in legislation introduced and passed restricting or banning our sales
and marketing activities; 2) Passage of legislation favorable to the industry; 3) greater
support from business, parent, and teacher groups.”
[Joshua Slavitt. Philip Morris, “Tobacco Industry Youth Initiative,” 1991] [5]
A cigarette for the beginner is a symbolic act. I am no longer my mother's child. I'm
tough. I am an adventurer. I'm not square ... As the force from the psychological
symbolism subsides, the pharmacological effect takes over to sustain the habit.'
[Philip Morris, 1969][6]
THE TOBACCO EPIDEMIC: A CRISIS OF
STARTLING DIMENSIONS
Tobacco kills nearly 10,000 people every day
The facts speak for themselves. Tobacco use worldwide has reached the proportion of a
global epidemic with little sign of abatement. Each year, tobacco causes about three and a
half million deaths throughout the world. This translates to nearly ten thousand deaths per
day. Based on current trends, this will increase to ten million annual deaths during the
2020s or 2030s, with seven million of these deaths occurring in developing countries.
Based on current patterns of consumption, it is predicted that over 500 million people
currently alive will be killed by tobacco.
in developed countries, where smoking became widespread during the 1940s and 1950s.
the catastrophic effect of past smoking trends can now be seen. About 20% of all deaths
occurring at present in developed countries are due to tobacco. By 2020, it is predicted
that tobacco use will cause over 12% of all deaths globally. By 2020, it is predicted that
tobacco will cause more deaths worldwide than HIV, tuberculosis, maternal mortality,
motor vehicle accidents, suicide and homicide combined.
HOW TOBACCO AFFECTS YOUNG PEOPLE
Tobacco affects young people in an extraordinary number of ways. Due to environmental
tobacco smoke (ETS) and maternal smoking, children’s health may even be compromised
from before the time they are bom. In many countries, children may grow up in a haze of
tobacco smoke, wreaking further havoc with tlieir health. Household money that is spent
on tobacco reduces the amount available for food, education and medical care. Children
may also suffer the emotional pain and financial insecurity that comes from the loss of a
parent or caretaker who dies an untimely death due to tobacco.
On another level are the pervasive pressures for young people to use tobacco. People
everywhere seem to be smoking. Attractive advertisements and exciting tobacco
promotions are difficult to resist. Especially when the price is affordable, and it’s no
problem for minors to buy tobacco.
Even if the health risks are understood, the message that tobacco kills is not very relevant
to young smokers, who believe themselves to be immortal. By the time they are ready to
quit smoking, addiction has taken hold. These factors all contribute to the grim statistics.
Based on current trends, about 250 million children alive in the world today will
eventually be killed by tobacco.
WHO believes that every child has the right to grow up without tobacco. This means
without the rampant pressures to use tobacco, which in many countries emanates from all
corners. There is a need to change the environment to one where non-smoking is
considered normal social behviour and where the choice not to smoke is the easier
choice.
Tobacco is fast becoming a greater cause of death and disability than any
single disease
Research shows that the risks from smoking are substantially higher than previously
thought. With prolonged smoking, smokers have a death rate about three times higher
than non-smokers at all ages starting from young adulthood. On average, smokers who
begin smoking in adolescence and continue to smoke regularly have a 50% chance of
dying from tobacco. And half of these will die in middle age, before age seventy, losing
around 22 years of normal life expectancy. Therefore, a lifelong smoker is as likely to die
as a direct result of tobacco use as from all other potential causes of death combined.
Tobacco is a known or probable cause of about 25 diseases, and the sheer scale of its
impact on global disease burden is still not fully appreciated. For example, it is well
know' that tobacco is the most important cause of lung cancer. Less know n is the fact that
tobacco kills more people through many other diseases, including cancers in other parts
of the body, heart disease, stroke, emphysema and other chronic diseases. Studies in the
United Kingdom have shown that smokers in their 30s and 40s are five times more likely
to have a heart attack than non-smokers.
TOBACCO USE IS A KNOWN
OR PROBABLE CAUSE OF DEATH FROM:
Respiratory diseases:
Cancers of the:
Lip, oral cavity and pharynx
Oesophagus
Pancreas
Larynx
Lung, trachea and bronchus
Urinary bladder
Kidney and other urinary organs
Cardiovascular diseases:
Rheumatic heart disease
Hypertension
Ischaemic heart disease
Pulmonary heart disease
Other heart diseases
Cerebrovascular diseases
Atherosclerosis
Aortic aneurysm
Other arterial diseases
•
•
•
•
•
Tuberculosis
Pneumonia and
influenza
Bronchitis and
emphysema
Asthma
Chronic airway
obstruction
Paediatric diseases:
•
•
•
•
Low birth weight
Respiratory distress
syndrome
Newborn respiratory
conditions
Sudden infant death
syndrome
Lung cancer and other
diseases caused by passive
smoking
Fires caused by smoking
materials
According to WHO estimates, there are around 1.1 billion smokers in the world-about
one-third of the global population aged 15 years and over. Of these, 800 million arc in
developing countries. Data suggest that, globally, approximately 47% of men and 12% of
women smoke. In developing countries, 48% of men and 7% of women smoke, while in
developed countries, 42% of men smoke as do 24% of women. By the mid 2020s, the
transfer of the tobacco epidemic from rich to poor countries will be well advanced, with
only about 15% of the world’s smokers living in rich countries. Health care facilities in
poorer countries will be hopelessly inadequate to cope with this epidemic.
In certain regions, the health consequences of tobacco use are particularly devastating. In
the Former Socialist Economies, around 17% of all deaths in 1995 were due to tobacco
use. This figure is expected to increase so that in 2020, more than 22% of all deaths in
this region will be due to tobacco. In 1995. it was estimated that 41% of all deaths among
men aged 35-69 years in this region were caused by tobacco.
There has occured a shifting of the tobacco epidemic. The apparent success in tobacco
control in some countries has been negated by growth in tobacco use in less developed
countries. So, globally there has been no net progress in reducing tobacco consumption.
In absolute figures, the biggest and sharpest increases in disease burden are expected in
India and China, where the use of tobacco has grown most steeply. In China alone, where
there are about 300 million smokers, new data show there are already about threequarters of a million deaths a year caused by tobacco. Based on current trends, of all the
children and young people under the age of 20 years alive today in China, at least 50
million of these will eventually die prematurely because of tobacco use.
Although life expectancy for both sexes is predicted to rise, in many countries, the gap
between them is growing significantly due to the large number of men who smoke and
die of tobacco-related diseases. However, the number of women and girls w ho smoke is
also rising, and so too will the number of tobacco-related deaths among women.
HEALTH BENEFITS OF QUITTING SMOKING
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•
•
One year after quitting, the risk of coronary heart disease (CHD) decreases by
50%, and within 15 years, the relative risk of dying from CHD for an ex-smoker
approaches that of a long-time non-smoker.
The relative risk of developing lung cancer, chronic obstructive lung diseases, and
stroke also decreases, but more slowly.
Ten to fourteen years after smoking cessation, the risk of mortality from cancer
decreases to nearly that of those who have never
smoked.
Quitting smoking benefits health, no matter at what age one quits.
I ENVIRONMENTAL TOBACCO SMOKE SERIOUSLY DAMAGES HEALTH OF
NON-SMOKERS
Environmental tobacco smoke (ETS) contains basically all of the same carcinogens and
toxic agents that are inhaled directly by smokers. Evidence is quickly mounting as to the
serious health consequences of ETS. both for adults and for children. These Endings
make a strong case for swift and tough policies to limit smoking in public places.
Exposure to ETS is a cause of disease, including lung cancer and possibly coronary heart
disease in healthy non-smokers. Prolonged exposure to environmental tobacco smoke
increases the risks of lung cancer and heart disease in healthy adults, possibly by as much
as 20-30%.
ETS can also result in aggravated asthmatic conditions, impaired blood circulation,
bronchitis and pneumonia. It also is a frequent cause of eye and nasal irritation.
Health consequences of ETS particular to young people:
Children exposed to ETS
•
•
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•
get more coughs and colds and are more likely to suffer acute upper and lower
respiratory tract infections. One study showed that children exposed to ETS
during the first 18 months of life have a 60% increase in the risk of developing
lower respiratory illnesses such as croup, bronchitis, bronchiolitis and pneumonia.
have an increased chance of developing asthma. If they already have asthma,
second-hand smoke can bring on asthma attacks and make them worse.
are at risk of impaired lung function, and may have breathing problems in the
future.
have an increased frequency of middle-ear infections, which can lead to reduced
hearing.
Babies born to women who smoke during pregnancy, as well as those infants
exposed to ETS have a significantly greater risk of dying of sudden infant death
syndrome (SIDS).
Smokeless tobacco use - A growing addiction
Smokeless tobacco is used in many forms around the world. In the United States and
parts of Europe, it is marketed as chewing tobacco and as oral snuff. In south and south
east Asia, it is most commonly consumed in a 'betel quid' or 'pan' consisting of tobacco
flakes, mixed with powdered or chopped areca nut, slaked lime and catechu, wrapped in a
betel leaf. This practice is a part of culture and tradition. Smokeless tobacco use has also
been reported in parts of Africa and the former Soviet Union. In India, the more recent
trend of chewing prepacked powdered areca nut with tobacco, lime and catechu (termed
'pan masala') has started to replace the habit of betel quid chewing. In Sudan, "toombak"
is used orally, while "nass" is widely used in Central Asian republics.
Although the term "smokeless tobacco" is commonly used for tobacco products used
orally, this is a term promoted by the tobacco industry that suggests that the product is
harmless. To avoid that innocuous connotation, the term "spit tobacco" is increasingly
used in countries such as the United States.
In the United States, recent surveys have shown alarming increases in use of spit tobacco
among children and younger adults . This increase is primarily due to the growing
popularity of oral snuff use among teenage and young adolescent males. It is estimated
that in one million adolescent boys in the USA use spit tobacco. Spit tobacco is also used
by many athletes, particularly baseball players, who are often role models for these boys.
Other populations with notable patterns of spit tobacco consumption are south and
southeast Asian immigrant communities in the United States and the United Kingdom.
These groups continue to use spit tobacco products manufactured and imported from the
Indian subcontinent.
Use of smokeless tobacco, including snuff and chewing tobacco varieties, has been
established to cause oral cancer (one of the ten leading cancers worldwide), irreversible
gingival recession, other oral pathologies, nicotine addiction and cardiovascular diseases.
Smokeless tobacco and betel quid chewing, particularly with tobacco, is the most
common cause of oral cancer in high incidence regions, and ranks globally as the greatest
single risk factor for oral cancer. There have been cases of six year old children in India
with submucous fibrosis, a precancerous condition . In south and southeast Asia, more
than 100,000 new cases of oral cancer are diagnosed annually. Some 1,700 and 30,000
cases of oral cancer are diagnosed in the UK and the USA respectively, each year. It is
believed that as many as 75% of oral cancers diagnosed in the United States are attributed
to regular use of smokeless tobacco products and alcohol combined.
- Media
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